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IS^Biik 


GIFT 
Dr    Adelaide  B  roim 


lANfeMcDCALimRARY 
^.ORDUKIVWSKY 

5J;;Sb>.CAUF.  94305 


GYNECOLOGICAL    DIAGNOSIS 


GYNECOLOGICAL 
DIAGNOSIS 


BY 

WALTER  L.  BURR  AGE,  A.M.,  M.D.  (Harv.) 

Fellow-  of  the  American  Gynecological  Society ;  Mcml)er  of  the  Obstetrical  Society  of 
Boston ;  Consulting  (rynecologist  to  SL  Elizabeth's  Hospital ;  Formerly  Vbiting 
Gynecologist  to  St.  £lizal)eth*8  and  the  Camey  Hospitals  ;  Electro- 
Therapeutist  and  Surgeon  to  Out- Patients,  Free  Hospital 
for  Women;    Qinical  Instructor  in  Gynecology, 
Hananl  T^niversity,  and  Instructor  in 
Operative  (»ynecol«gy  in  the 
Boston  Polyclinic 


WITH  TWO  HUNDRED  AND  SEVEN  TEXT  ILLUSTRATIONS 


NEW   YORK   AND    LONDON 
D.  APPLETON  AND   COMPANY 

1910 


Coptright;  1910,  by 
D.  APPLETON  AND  COMPANY 


FRINTED  IN  NEW  YORK,  U.   B.  A. 


"  Find  out  the  cause  of  this  effect — 
Or  rather  say,  the  cause  of  this  defect. 
For  this  effect  defective  comes  by  cause." 

— Hamlet f  Act  ii.  Scene  2. 


PREFACE 

Some  years  ago  a  prominent  surgeon  who  had  been  atteading  one 
of  tny  clinics,  remarked  when  the  elinic  w^aa  over:  **  1  think  I  imder- 
8tand  the  treatment  and  I  know  how  to  do  most  of  the  gynecological 
operations,  but  where  I  find  great  difficulty  is  in  the  tliagnosis." 

At  the  present  time  the  medical  profession  is  devoting  an  ever- 
tncrcddtng  amount  of  attention  to  diagnosis,  and  it  seems  fitting  to 
describe  at  length  this  somewhat  blind  subject,  gynecology,  for  the 
benefit  of  those  who  have  not  had  an  opportunity  to  study  it  in  the 
special  hospitals  and  clinics, 

A  practical  text-book,  embodying  simplirity  of  tcclmique  and 
concise  statement  of  esscntialH^  ha^*  l>een  the  aim.  The  methods  of 
procedure  of  the  pathological  and  bacteriological  laboratories  have 
been  omitted  because  of  the  assumption  that  the  physician  in  making 

'  m  diagnosis  has  always  at  his  ronmmnd  the  services  of  a  trained 
pathologist  and  bacteriologist,  or  can  consult  text-books  devoted 
exclusively  to  thpse  subjects.  The  attempt  has  been  made  to  keep  in 
the  background  the  rare  diseases  which  are  of  so  much  interest  to  the 
^lecialist  and  to  give  prominence  to  the  common  affections  usually 
met  by  the  general  practitioner.  While  the  book  is  written  entirely 
fram  the  clijiical  point  of  view,  the  salient  points  of  the  anatomy 
the  latest  \dews  of  the  pathology'  have  been  summarized  at  the 

jbegmning  of  each  chapter,  and  the  literature  has  been  scanned  for  new 

f ideas  of  value  to  the  practitioner. 

The  differential  diagnosis  is  entered  into  extensively  and  is  sum- 
jDArixecl  in  many  places  in  the  form  of  tables  of  parallel  columns. 

Particular  attention  has  been  paid  to  the  diagnosis  of  the  diseases 
of  the  bladder  and  of  the  rectum  because  of  my  belief  that  these 
OJ-gana  are  too  often  neglected.    A  chapter  on  diseases  of  the  l)reast 

jfhms  been  includetl  because  the  breast  is  a  part  of  the  reproductive 
pm  in  w'oraen  and  has  intimate  relationship  with  the  uterine 

[Ofg^ivi^    The  importance  of  the  recognition  of  uterine  disease  in  early 

l]sfe|  which,  wiien  undiscovered,  frequently  causes  disastrous  results 
later,  has  led  to  the  writing  of  the  chapter  on  the  g}^necological  affec- 
tiona  of  infancy  and  childhood.  In  the  preparation  of  this  chapter 
I  have  been  fortunate  in  having  the  assistance  of  my  friend,  Dr. 


viii  PREFACE 

John  Lovett  Morse,  who  kindly  revised  the  manuscript.  The  chapter 
on  the  menopause  is  an  attempt  to  shed  light  on  this  important  but 
little  understood  period  of  woman's  life. 

An  original  feature  of  the  book  is  an  alphabetical  index  of  illus- 
trations— of  which  there  are  two  hundred  and  fifteen — ^in  the  front. 
Thus  the  reader  can  find  any  desired  figure  without  laboriously 
going  through  the  entire  list.  The  attempt  has  been  made  to  place  each 
figure  next  to  the  text  it  illustrates  and  all  references  to  figures,  as  well 
as  to  subjects  cited  in  other  parts  of  the  book,  are  accompanied  by 
page  numbers.  Every  chapter  is  headed  by  a  rdsum^  of  its  contents 
with  page  references,  and  all  the  illustrations,  as  well  as  the  titles  of 
the  subject-matter,  are  also  included  in  a  vcrj^  full  index  at  the  end. 

The  views  here  expressed  and  the  methods  described  are  those 
that  have  found  favor  in  my  practice,  and  they  arc  put  forward  not 
with  the  feeling  that  they  arc  new,  original,  or  all-inclusive,  but  that 
having  proved  useful  to  me  they  may  help  others  also  to  unravel  the 
knotty  problems  of  gynecology. 

My  thanks  are  due  to  Dr.  Howard  A.  Kelly,  Dr.  E.  C.  Dudley,  and 
the  other  authors  who  have  kindly  loaned  illustrations  from  their 
works;  to  Dr.  Henry  T.  Hutchins  for  revising  the  chapter  on  malig- 
nant diseases  of  the  uterus  and  the  section  on  the  collection  of  the 
discharges  and  tissues  for  microscopic  examination;  to  Dr.  Howard 
W.  Beal  for  assistance  with  the  section  on  indirect  cystoscopy;  to 
Miss  Florence  L.  Spaulding  and  Miss  Ruth  O.  Huestis  for  original 
drawings;  and  especially  to  Messrs.  D.  Applcton  and  Company, 
who  have  shown  never-failing  courtesy  and  who  have  assisted  in  every 
possible  way  in  the  making  of  the  book. 

Walter  L.  Burrage. 
Boston 


CONTENTS 


PART  I 

GENERAL  CONSIDERATIONS 

PAGE 

Chapter  I.  Introduction 3 

Chapter  II.        The  Clinical  History 6 

Chapter  III.       The  Interpretation  op  the  Cunical  History      .    .        9 

Chapter  IV.       The  Physical  Examination       23 

I.  The  preparation  of  the  patient. — II.  The  prepar- 
ation of  the  examining  table. — III.  The  exam- 
ination: 1.  Preparation  of  the  physician  and 
placing  the  patient  on  the  table.  2.  Inspection 
of  the  external  genitals.    3.  Palpation. 

Chapter  V.         The  Physical  Examination  (CorUinued) 43 

III.  The  examination  (corUmued):  3.  Palpation 
(continued).  4.  Odor  as  a  diagnostic  sign.  5.  The 
collection  of  the  discharges  and  tissues  for  micro- 
scopic examination. 

Chapter  VI.        The  Physical  Examination  (CorUinued) 64 

III.  The  examination  (continued):  6.  Inspection  of 
the  abdomen.  7.  Palpation  of  the  abdomen. 
8.  Percussion  of  the  abdomen. 

Chapter  VII.      The  Physical  Examination  (Concluded) 77 

III.  The  examination  (continued):  9.  Instruments 
and  their  use  in  diagnosis. 

Chapter  VIII.    The  Investigation  of  the  Urethra,  Bladder,  and 

Ureters 99 

Chapter  IX.       The  Investigation  of  the  Rectum 121 

Chapter  X.         The  Significance  of  the  Chief  Symptoms  of  Pelvic 

Disease 127 

ix 


CONTENTS 


Chapter  XI. 
Chapter  XII. 
Chapter  XIII. 

Chapter  XIV. 
Chapter  XV. 
Chapter  XVI. 

Chapter  XVII. 
Chapter  XVIII. 
Chapter  XIX. 
Chapter  XX. 
Chapter  XXI. 
Chapter  XXII. 

Chapter  XXIH. 
Chapter  XXIV. 
Chapter  XXV. 
Chapter  XXVI. 
Chapter  XXVII. 
Chapter  XXVIII. 

Chapter  XXIX. 


PART  n 

SPECIAL    DIAGNOSIS 

PAOK 

The  Diagnosis  of  Endometritis,  Including  Gonor- 
rhea and  Erosions  of  the  Cervix  Uteki   .     .     .  165 

The    Diagnosis    of  Pelvic  Infl.\mmation   (Pelvic 

Peritonitis  and  Pelvic  Cellulitis)      .     .     .  187 

The  Diagnosis  op  Congenital  Anomalies  of  the 
Uterus,  Laceration  of  the  Cervix  Uteri,  and 

Diseases  of  the  Uterine  Ligaments     ....  197 

The  Diagnosis  of  Malpositions  of  the  Uterus    .  215 

The  Diagnosis  op  Fibroid  Tumors  of  the  Uterus  244 

The    Diagnosis   of   Malignant   Diseases   of  the 

Uterus 266 

The  Diagnosis  of  Diseases  of  the  Ovaries      .     .  284 

The  Diagnosis  of  Diseases  of  the  Fallopian  Tubes  324 

The  Diagnosis  of  Extra-L'terine  Pregnancy  .     .  340 

The  Diagnosis  of  Diskasf-s  of  the  Vagina  .     .     .  354 

The  Diagnosis  of  Diseases  op  the  Vulv-^    .     .     .  388 

The  Diagnosis  of  Uterine  Pregnancy,  Abortion, 

AND  Hydatidiform  Mole 417 

The  Diagnosis  of  Diseases  of  the  Urethra    .     .  444 

The  Diagnosis  of  Diseases  op  the  Bladder     .     .  457 

The  Diagnosis  of  Diseases  op  the  Ureters     .     .  486 

The  Diagnosis  op  Diseases  of  the  Rectum      .     .  494 

The  Diagnosis  of  Diseases  of  the  Breast       .    .  531 

The  Diagnosis  of  the  Gynecological  Affections 

OF  Infancy  and  Childhood 555 

The  Menopause  and  Old  Age 587 

INDEX 627 


LIST  OF  ILLUSTRATIONS 


FIO.  PAOE 

Abdomen,  cavity  of,  shape  of 86  221 

division  of,  into  quadrants  and  indication  of  bony  landmarks       .     18  65 

organs  of,  origin  of  tumors  in 129  304 

Anal  canal 191  495 

cast  of         192  496 

Anal  region,  diagram  of 195  515 

Applicator,  uterine       37  93 

Ascites,  abdomen  of,  seen  in  profile 131  307 

cross  section  of ,  dorsal  position 132  310 

lateral  position       133  311 

Bartholin's  gland,  cyst  of  left        174  409 

Bartholin's  glands,  abscess  of 176  411 

abscess  of  ducts  of 175  410 

Bladder,  ballooned  by  air,  patient  in  knee-chest  position 54  112 

base  of,  showing  diverticula        185  458 

norma],  laid  open  from  in  front 51  106 

overdistended        84a  217 

papilloma  of         190  482 

stone  in       186  463 

tuberculosis  of  ureteral  orifice  in 187  469 

varix  of       188  474 

Bladder  phantom,  for  practising  cystoscopy 58  118 

Blood  vessels,  uterine  and  ovarian 8  47 

Body,  vertical  median  section  of 6  44 

of  childbearing  woman              84  216 

Breast,  diffuse  bilateral  hypertrophy  of 201  541 

(liKsection  of  lower  half  of,  showing  milk  ducts 198  534 

division  of,  into  quadrants 200  538 

lymphatics  of       199  535 

right,  vertical  section  of     » 197  533 

scirrhous  cancer  of 202  547 

Calibrator,  meatus,  Kelly 44  101 

Carunculff  myrtiformes         165  397 

Catheter,  bladder,  long  silver 43  101 

ureteral,  Kelly 48  103 

Orvix,  adeno-cardnoma  of  canal  of,  early  stage HI  268 

cancer  of ,  early  stage 110  267 

erosion  of,  with  lacerations 69  185 

fibroid  of 108  254 

hypertrophic  elongation  of 88a  225 

xi 


3ai  LIST  OF  ILLUSTRATIONS 

no.  PAGE 

Cervix,  laceration  of,  bilateral,  with  erosions 79  205 

crescentio 81  207 

stellate 80  206 

unilateral  (diagram)       83  209 

with  eversion  of  lips  (diagram) 82  209 

prolapse  of 88  224 

squamous-celled  cancer  of,  early  stage 110  267 

supravaginal,  elongation  of 88  224 

Controller,  current,  for  use  with  electric  cystoscope 57  117 

Curette,  uterine       31  90 

Cylinder,  vertical,  filled  with  fluid,  representing  abdominal  cavity       .       7  45 

Cystocele         148  367 

diagram  of       148a  368 

Cystoscope,  bladder,  Kelly 49  104 

ureter,  Nitze 56  116 

Cystoscopy,  modified  knee-chest  position  used  in 53  111 

removing  urine  from  bladder  in,  by  suction  apparatus 55  113 

Decidua,  uterine,  in  extraruterine  pregnancy 143  345 

Depressor,  vaginal.  Hunter        29  89 

Dilator,  urethral,  double-ended,  Kelly       45  102 

uterine,  Wathen        . 34  92 

uterine.  Hanks 33  91 

Endometrium,  normal ^65  167 

Enteroptosis,  body  pose  in 19  67 

Evacuator,  bladder,  Kelly 46  102 

wash-bottle,  Kelly 55  113 

Extra-uterine  pregnancy,  ampullar,  early 140  341 

mole  and  fetus  removed 141  342 

ampullar,  late 145  350 

isthmial,  section  of  uterus  of 146  352 

Fallopian  tubes,  development  of,  in  fetus 71  198 

Fissure  in  ano 194  504 

Fistula  in  ano,  blind  internal 196a  517 

complete 196  517 

Fistulae,  genital,  scheme  of,  after  Dudley          189  476 

after  Gilliam 155  385 

Forceps,  bladder,  alligator 50  105 

curette,  Emmet         30  89 

rectal,  alligator 62  125 

uterine  dressing,  Bozeman 23  83 

vulselliun 25  84 

Gauze  records  of  abdominal  tumors 20  75 

Genital  organs,  development  of,  five  diagrams  illustrating      .     .     158-162  395 

external,  at  beginning  of  third  month 157  392 

Gland,  Bartholin's,  cyst  ofleft        174  409 


LIST  OF  ILLUSTRATIONS  xiii 

no.  PAGE 

Glands,  Bartholin's,  abscess  of 176  411 

abscess  of  ducts  of 175  410 

Hand,  examining,  showing  protective  sleeve 2  31 

Hegar's  method  of  palpating  pedicle  of  ovarian  tumor 126  301 

sign,  bimanual  palpation  for       179  425 

Hematocele,  pelvic       142  343 

Hcmatocolpos,  diagram  of 171  398 

Hcmatometra,  diagram  of 172  398 

Hematosalpinx 139  'S'<i5 

diagram  of       173  399 

Hemorrhoids,  types  of •  .     .     .  193  499 

Hydatidiform  mole 182  442 

Hydrosalpinx 138  334 

Hymen,  different  forms  of 163-170  397 

Interstitial  pregnancy        144  346 

Irrigator,  uterine,  Bozeman-Fritsch 35  92 

Isthmial  tubal  pregnancy,  section  of  uterus  of 146  352 

LiG.vMENTS,  utero-sacral,  course  of,  in  intraligamentous  tumor       .     .  135  317 

in  retroperitoneal  tumor 134  316 

Mattrfty,  precocious,  case  of    .     . 207  565 

**Milkline," 200  538 

Os.  external,  parous 66a  169 

virginal 66  168 

Ovaries,  infantile 117  286 

Ovary,  cyst  and  timior  regions  of 120  290 

c>'st  of.  adherent,  arrangement  of  peritoneum  in 124  292 

intraligamentous,  arrangement  of  peritoneum  in        123  292 

pedicle,  arrangement  of  peritoneum  in 122  292 

very  large,  showing  emaciation  and  '*  facies  ovarina  "     .     .     .     .  125  294 

normal,  pedicle,  arrangement  of  peritoneum  in 121  292 

of  mature  woman 118  287 

senile 119  289 

tumor  of ,  cross  section  of  body  of 127  302 

tumors  of,  Hegar's  method  of  determining  relation  of,  to  ut«nis      .  126  301 

pedicle,  formation  of  (4  diagrams) 121-124  292 

Ovary  and  tube  seen  from  behind 116  285 

Parovarii-m,  large  cyst  of,  seen  in  profile 128  303 

Peh-imeter       .     .     / ....     42  98 

Pelvis,  contents  of,  from  aV>ove 9  48 

female,  normal 9a  50 

showing  accewibility  of  contents  to  pali)ation 10  52 

with  hand  in  position  as  for  vaginal  examination 4  37 

floor  of,  diagram  showing  structures  of 150  373 

of  new-bom  child,  longitudinal  median  section  of 204  558 


xiv  LIST  OF  ILLUSTRATIONS 

VIG.  PAQK 

Perineum,  laceration  of,  complete  median 151  374 

partial  lateral 152  375 

Peritoneum,  reflections  of  folds  of,  in  pelvis        70  189 

Position,  dorsal        3  32 

knee-chest        13  56 

bladder,  vagina,  and  rectimi  ballooned  by  air  in 54  112 

modified  for  cystoscopy 53  111 

side-view,  showing  vertical  thighs 14  57 

lithotomy          15  58 

raised  pelvis 16  59 

Sims        11  53 

diagram  of        12  54 

standing 17  60 

Precocious  maturity,  case  of 207  565 

Pregnancy,  extraruterine.     See  Extra-uterine  pregnancy 

interstitial        144  346 

tubal,  early  ampullar,  abortion  in 140  341 

mole  and  fetus  removed  from  tube 141  342 

bthmial,  uterus  of 146  352 

late  ampullar,  four  months' 145  350 

section  of  uterus,  showing  decidual  modiflcation  in 146  352 

Probe,  uterine 22  82 

Procidentia          87  223 

Proctoscope,  long 61  124 

short       60  123 

Pyosalpinx 137  333 

Rbgtocelb 149  369 

diagram  of 149a  370 

Rectum,  ballooned  by  air,  patient  in  knee-chest  position 54  112 

lower  part  of ,  diagram  of 195  515 

SAU»iNGins,  tuberculous 136  331 

Searcher,  ureteral,  Kelly       47  102 

Soimd,  uterine 21  78 

Separator,  urine,  Luys 59  119 

Speculum,  bivalve.     See  Speculum,  vaginal,  Brewer  and  Graves 

rectal,  Sims 63  126 

uterine,  Burrage       36  93 

vaginal.  Brewer 26  87 

Edebohls 32  91 

Graves 27  87 

Sims 28  88 


Table,  examining 1  27 

Tenaculimi,  uterine 24  83 

Touch,  bimanual,  diagrammatic  drawing 5  38 

Tubercles  of  bladder  waU 187  469 


LIST  OF  ILLUSTRATIONS  xv 

no.  PAGE 

Urkter,  orifice  of ,  jet  of  urine  spurting  from 52  107 

Urethra,  caruncle  of * 184  454 

mucous  membrane  of,  prolapse  of 183  449 

Uterine  organs  of  an  infant  at  birth  seen  from  above 205  562 

Uterus,  anteflexion  of,  in  the  little  girl 90  230 

pathological 91  231 

bicomis        74  199 

bicomute.  one  external  os,  two  uterine  cavities 78  201 

bipartitus         72  199 

body  of,  adeno-carcinoma  of,  early  stage 112  269 

horizontal  section  of  upper  part  of 67  171 

sarcoma  of 113  279 

cavity  of,  Kelly's  methods  of  exploration  of,  exploring  with  finger      41  97 

incising  ant^^rior  wall 39  95 

transverse  incision  anterior  to  cervix 38  94 

laid  open        40  96 

chorioepithelioma  of  posterior  wall  of 114  281 

development  of,  in  fetus 71  198 

didelphys 73  199 

douV)le.  with  double  vagina 147  358 

fibroids  of.  intt^rstitiul  and  submucous 104  248 

intraligamentous         105  249 

large  tumor  filling  pelvis  and  simulating  pregnancy       ....  109  256 

multiple 102  246 

polyp  in  vagina,  large 107  252 

submucous,  large,  showing  distortion  of  uterine  cavity     ....  106  250 

simulating  inversion 101  245 

pedimculated,  simulating  inversion        99  241 

simulating  partial  inversion        95  241 

suV)serous.  side  view  of  abdomen  containing  large  tumor       .     J     .  103  247 

tumor  of  cer\'ix 108  254 

fundus  of,  height  at  various  wet»ks  of  pregnancy 130  306 

inversion  of  acute  puerperal 93  239 

complete       98  241 

with  |)etlunculateil  subserous  fibroid  of  abdominal  evolution      .  100  241 

partial 97  241 

ttiiLse*!  by  suV)mucous  fibroid        296  241 

of  left  horn 94  241 

normal.  |H>sitionof 6  44 

pregnant,  enlargement  of,  in  late  pregnancy 181  428 

pregnant  at  sixth  week,  diagrammatic  side  view,  during  contraction    178  423 

during  relaxation        177  422 

section  of 178  424 

prolapse  of 87  223 

partial 89  227 

recon.stniction   of,  showing  shape  of  uterine  cavity   and   cervical 

canal 64  166 

ret  roposition  with  anteflexion 91  231 

retroversion  of .    92  235 

caused  by  overdistended  bladder 84a  217 


xvi  LIST  OF  ILLUSTRATIONS 

na.  PAGE 

Uterus,  sarcoma  of       113  279 

section  of,  in  isthmial  tubal  pregnancy 146  352 

transverse  longitudinal 68  172 

septus 75  199 

unicornis , 76  199 

with  accessory  comu 77  199 

Vagina,  ballooned  by  air,  patient  in  knee-chest  position 54  112 

chorioepithelioma  of,  metastatic 115  282 

cyst  of  anterior  wall  of 154  381 

cyst  of  posterior  wall  of 153  380 

development  of,  in  the  fetus 71  198 

double,  with  double  uterus 147  358 

infantile,  examination  of,  with  cystoscope 205  559 

longitudinal  section  of,  showing  S-shaped  curve 85  219 

prolapse  of 88  224 

Vulva,  at  beginning  of  third  month  of  fetal  life 157  392 

diagram  of 156  389 

infantile 203  556 


PART    I 
(JENERAL    CONSIDERATIONS 


CILIPTER  I 


INTKODUCTION 


Diagnosis,  tho  foundation  of  gynecology,  h  elusive.  The  con- 
sultant frequently  hears  it  said  l)y  the  attending  physician^  **  Doc- 
tor, I  know  how  to  do  this  operation,  but  what  puzzles  mc  is  to 
know  when  it  is  intUcateil" 

The  etiueateil  toueh  is  the  keystone  of  the  diapiostie  arch; 
gymptomutology,  sight,  instninientation*  niicro^eopie  fimlings,  are 
but  accessories.  To  train  the  toueh  reciuires  time  and  application. 
Ai?  in  learning  any  handicraft,  the  beginning  is  of  great  inipoilanee. 
Tho:<e  who  neglect  to  perfect  themselves  in  the  proper  technit[Ue 
at  the  fttart,  who  never  aefjuire  *'  geKxl  fonn  "  as  they  say  in  athletics, 
never  progress  beyontl  a  mtxlerate  degi*ee  of  excellence.  The 
,  practitioner  who  pei-sists  in  making  the  bimanual  examination  with 
the  i^atient  in  bed  or  on  a  yielduig  surface,  or  neglects  to  incoMimodc 
her  to  the  extent  of  causing  to  be  Io*jsene<i  all  clothing  alx>ut  the 
wai8t ,  never  bi'comes.  a  good  diagno^lician.  The  rc^asons  for  this 
will  apjiear  later. 

There  is  no  department  of  medicine  in  which  the  patient  is  less 
able  to  judge  from  her  own  observation  of  the  corriH^tness  of  the 
^diagnosis  than  in  gpiecology.  Unlike  tlie  dermatologist,  for  ex- 
ample, the  gjTieeologist  docs  not  have  trained  ufjon  his  work  the 
critical  eye  of  his  patient. 

She  is  unable,  also,  to  judge  of  the  nature  of  the  treatment  em- 
ploye*!.  It  is  espc^eially  easy  for  a  physician  who  has  made  an  error 
in  diagnosis  to  |)ersist  in  a  chosen  line  of  treatment  without  dis- 
covering his  mistake^  for  the  illations  between  eaust*  and  efiTect  are 
often  incmi  sha<lowy;  also,  consultations  are  relatively  infreipient 
in  this  clepartinent  of  medicine.  Because  of  the  delicate  nature 
of  the  confidences  calkMi  for.  and  the  sensitive  portion  of  the 
anatomy  iuvoIvkI,  the  patient  shrinks  fmtn  subjecting  herself  to 
repeated  examinations  at  the  hands  of  different  physicians. 


4  INTRODUCTION 

We  have  to  do  in  this  book  with  the  question  of  diagnosis  alone 
and  it  will  be  my  endeavor  to  point  out  how  best  to  make  it.  More 
stress  wall  be  laid  on  the  interpretation  of  symptoms  and  signs  in 
the  light  of  experience  than  is  usual  in  text-books  on  gynecology 
because  it  is  thought  thereby  to  help  the  practitioner. 

That  pathological  conditions  may  exist  without  any  symptoms 
at  all  should  never  be  forgotten.  For  instance,  a  woman  may  have 
a  double  uterus,  detected  for  the  first  time  at  the  gynecological 
examination  which  follows  labor,  or  a  patient  may  have  a  small 
dermoid  tumor  of  the  ovary,  discovered  only  when  she  comes  to 
the  physician  to  learn  why  she  has  never  had  children. 

A  judicious  combination  of  the  deductive  and  inductive  methods 
seems  to  be  the  most  practical  way  of  presenting  the  subject;  a 
result  accomplished  by  describing  the  steps  of  the  examination  and 
the  processes  followed  in  arriving  at  a  diagnosis,  as  nearly  as  may  be, 
as  they  occur  in  actual  practice. 

Particular  attention  is  paid  to  the  minutiae  of  the  history-taking, 
the  management  of  the  patient,  and  the  smallest  details  of  the  ex- 
amination, because  of  my  belief  that  matters  which  seem  trivial  to 
many  are  in  reality  the  solid  groundwork  of  a  correct  diagnosis. 

Mistakes  in  diagnosis  are  unavoidable  even  in  the  exix»rience  of 
the  most  expert.  To  make  a  mistake  because  an  inadequate  ex- 
amination was  made  or  no  examination  at  all  is  an  unpardonable 
sin.  Experience  teaches  that  finality  in  diagnosis  is  not  always  a 
possibility  in  gynecology,  and  even  after  the  most  painstaking 
history,  analysis  of  the  symptoms,  and  physical  examination,  wp 
may  fail  to  distinguish  between  two  or  three  possible  conditions. 
Our  object  is  to  reduce  the  uncertain  cases  to  a  minimum. 


CTHPTER   II 


THE  CIJXHWL  HLSTORY 


cthod  of  getting  I  be  history,  p,  A.    Casp-rec*jrd  systems,  p.  0*     Form  for 
'^reciirdd,  p.  6, 


METHOD  OF  GETTING  THE  HISTORY 


I 


Many  busy  praetitionors  slight  the  clinical  hktofy,  the  taking 
of  which  should  prtTedc  evtiy  physical  examination.  This  is 
a  mistake  which  carries  its  own  retrilnitiou  in  the  form  of  a  slij)- 
ghoil  tUai^nosl'^.  A  clear  antl  exhaustive  history  not  only  serves  as 
a  guide  in  making  the  physical  exaiiiination,  but  also  develops 
gynjptonis  which  otherwise  may  Ix'  overlookcni.  There  are  few 
cafies  wWch  are  not  Ijetter  diagnosed  by  a  careful  preHniinar}' 
(|umtioning  of  the  patient.  The  physician  gains  liis  patient  s  con- 
fi4i«?nce,  so  necessary  for  a  successful  phy^^ical  examination.  If  she 
iKK-omi^s  prolix  or  strays  from  the  important  [loint,  a  <[uestion  will 
often  bring  her  back.  It  is  well  to  note  especially,  |>erhai>s  by 
underUning,  the  symptoms  that  seem  most  important  to  her,  so 
thai  in  subsiH[Uent  int^*rviews  these  may  Ix*  under  sjiecial  obser\"a- 
tion.  It  is  generally  lx»tter  to  talk  with  the  fiatient  alone  when 
getting  the  history^  as  there  art'  imi>ortant  facts  which  will  Ije 
»uppn>is4>d  if  a  third  (X'rson,  whether  a  nurse  or  a  relative,  Im^  i)r<^ent, 
jometimc^^  it  hapiwMis,  however,  that  important  facts  are  to  f)e 
ined  from  the  husband,  and,  in  the  case  of  a  young  girh  from 
the  mother,  A  <lesiraljle  j^ractiee  is  to  review  the  history  after  the 
physical  examination  in  the  light  of  the  facts  brouglit  out  by  the 
examination  and  to  cross-question  the  patient  as  to  the  truth. 
Avoid  I  as  far  as  possible,  asking  leading  questions  ami  assenting 
to*>  n*AiUly  to  the  answers.  Be  sm'e  that  the  answers  represent  the 
truth. 

5 


THE    CLINICAL    HISTORY 


CASE-RECORD  SYSTEMS 


A  good  method  for  case  records  is  the  envelope,  card-catalogue 
system.  A  filing  cabinet  with  several  drawers  is  obtained.  Large, 
ungummed  envelopes,  and  also  a  si^t  of  cards  just  fitting  into  the 
envelopes  and  the  drawers  as  well,  are  procured.  For  use  at  the 
bedside  it  has  been  my  custom  to  carry  in  a  leather  pocket-case  a 
block  of  prescription  blanks,  six  by  four  inches,  which  fit  the  en- 
velopes of  my  filing  cabinet.  At  the  office  I  use  cards  of  the  same 
size.  Every  card  and  envelope  is  marked  on  the  left-hand  top 
comer  with  the  patient's  name  and  filed  alphabetically  in  the 
cabinet.  One  advantage  of  the  envoloix^  system  is  that  additional 
memoranda,  such  as  notes  on  tn^atment  and  other  data,  may  be 
filed  in  the  same  envelope,  and  it  is  not  necessary  to  copy  the  notes 
taken  at  the  bedside  bc^fore  filing  thc^m. 

Many  gynecologists  have  printed  case  sheets,  either  in  a  book  or 
as  loose  pages  or  cards.  It  is  well  to  have  some  schedule  to  follow 
so  that  the  same  order  may  be  observed  in  all  cases  and  important 
facts  may  not  be  omitted.  To  the  Ix^ginner  a  printed  form  is  in- 
valuable, but  to  the  physician  of  experience  it  is  hardly  worth  while 
to  take  up  desirable  room  on  the  cards  with  printing  which  may  be 
of  no  use  in  many  of  the  cases.  The  object  is  to  get  a  schedule  in 
mind,  rather  than  to  have  it  printed  before  you. 


FORM   FOR    CASE   RECORDS 

Date: 

Name  in  full : 

(In  the  case  of  a  married  woman  both  own  first  name  and  hus- 
band's first  name  for  purposes  of  future  identification.) 
Address :  Nationality  : 

Occupation :  Age : 

Social  Condition  :  Single.  Married,     (how  many  years) 

Widow :   (how  many  years) 
Children  :     (how  many  and  ages) 

Miscarriages  or  abortions  :    (number,  and  at  what  weeks  or  months 
of  pregnancy.) 


FORM  FOH  C.\SE  RECORDS 


Family  History. — General  |>mllspoi?ition  to  raiicer,  lung  trouble, 
heart  clii^rase,  kidney  disease,  or  rheunmti.^nh  If  the  parent.^  arc 
dead,  what  were  the  causes  of  death.  Early  or  late  occurrence  of 
the  fij^t  menstruation  and  of  the  menopause,  or  tlie  oecuri'enee  of 
dysnK*iion*heft  or  uterine  disease  in  gisters  or  female  relatives, 

Preiious  Hi-story. — Sfx*cial  reference  to  g\'necolo^cal  affections; 
a^  attacks  of  vnilvar  inflammation,  or  smarting  with  mictmition, 
as  Lnilicating  gonorrhea:  ''inflammation  of  the  bowels/*  as  indicat- 
ing pelvic  inflammation:  lack  ot  control  over  the  bowels  or  blatlder, 
showing  injury  of  the  siihincter  ani  <»r  of  the  pehic  Hoor;  the 
account  of  any  operation  which  may  liave  been  performed  on  the 
genital  organjs.  The  infectious  diseases  may  point  to  inflammatory 
afTections  of  the  %*ulva  and  vagiiia  in  childhood 

MeJu4riuUion. — Age  at  which  first  menstiTiation  occurred ;  whether 
normally  established,  the  subseijuent  rh3l:hm,  duration,  quantity, 
and  quality  of  the  flow;  whether  accompanietl  by  pelvic  pain,  if 
iK),  the  situation,  character,  anil  duration  of  the  pain,  also  whether 
before,  during,  or  after  the  flow;  whi*ther  distm-bances  of  other 
functions  at  the  time  of  menstruation,  as  naust^a,  headache,  dc^ 
presssion  of  spirit^s;  any  recent  irrc»giilarities  in  the  rh}ihm,  t)uan- 
tity,  or  character  of  the  flow;  intermenstrual  pain,  if  so,  exact  dates 
of  beginning  and  end  of  pain.  Is  menstruation  accompanied  by 
fc?ucorrhea,  or  not. 

Vaginal  Discharge. — Character,  amount,  when  most  in  quantity, 
duration. 

Pirin, — Other  than  menstnml,  situation,  duration,  I'liaracter. 

Con/memento,  Miscarria{i€s,  and  Af}orti(ms, — Labors  normal,  rapid, 
tedious,  or  instrmnental ;  whether  injuries  received  or  symptoms 
•tuffered:  convalescence  normal  or  not;  stitcht^s  taken,  ft*ver 
following,  MLscarriages  or  abortions,  dates  of  occurrence  and  at 
what  w*et*ks  of  pregnancy :  suppost^l  cause  or  »'auses ;  atti^nded  by 
much  flowing  or  fever;  convalescence,  good  or  bad. 

Bladder  Symptoms. — Frecjuency  of  micturition  by  day  and  by 

2:ht;   smarting  on  urination;   control  of  urine  on  laughing  and 

ighing  and  on  standing  and  walking:  pain  in  region  of  bladder 
on  micturition;  color  and  <[uantity  of  urine  |>ai^se<^L 

P3Fie$enl  Ithhess, — Duration;  jjarticulars  as  to  present  sjonptoms 
such  aa  puin,  situation,  character;   leucorrliea,  when  first  noticed, 


8  THE  CLINICAL  HISTORY 

character,  as  thin,  glairy,  thick,  purulent,  bloody,  or  offensive; 
whether  constant,  or  before  and  after  menstruation. 

Date  of  the  Beffinning  of  the  Last  Menstruation. 

Abdominal  Swelling. — When  first  noticed,  progressive  increase 
in  size,  stationary  or  smaller,  painful  or  not. 

Bowds, — ^Regular  movement  every  day  or  constipated;  full 
action  or  scanty;  liquid,  semi-solid,  or  solid  stools;  offensive  odor; 
gas  in  bowels;  blood,  mucus,  or  pus  with  the  stools;  painful  de- 
fecation. 

General  Health. — ^Appetite,  digestion,  sleep;  whether  an  increase 
or  decrease  in  body  weight;  headache;  backache. 

The  General  Appearance  of  the  patient  should  be  noted  as 
regards  height,  approximate  weight,  complexion,  color  of  lips, 
peculiarities  of  form,  if  any. 

Analysis  of  Urine. 

Treatment  Advised. 


CHAPTER   III 


THE   INTERPRETATION    OF  THE  CLINICAL   IHSTORY 

Tlic  address,  nationality,  antl  occupalion,  fi.  9.  A^\  f>.  9.  Social 
eomiition,  p.  10.  Dy imreuniii,  p.  H  (1nklrcii»  11.  Family  history,  p.  H. 
Previous  history  p,  V'i.  CoiistitulioiMil  diiseases,  p.  H.  Chief  complaint 
and  present  illness,  p.  15.  Menstruation,  p,  13:  Puberty,  p.  H;  The 
nienopause.  p.  16;  The  atrophic  changes  in  the  genital  organs  and  the 
body  alterations  of  the  nienopayse,  p.  17.  Vaginal  distl large,  p.  18.  Pain, 
p.  1ft  Backache,  p.  18,  Muscular  rheuniatisni,  p.  1!*;  Coc<"ygodynia. 
p.  1»;  Pains  in  the  groins,  p.  19.  Alj<li)niintil  swelling,  p.  ^>,  Bladder 
s)i]]pioms,  p.  iO,     The  l>owels,  p.  t\.     Present  illness,  p,  t^. 


This  is  a  chapter  of  probabilities :  not  instructions  how  to  make 
an  offliaml  diagnosis,  but  a  ^^ifting  of  ilic  ovidtiin*  as  it  is  preseiitetl, 
the  cUagnot^iH  toeing  held  in  reserve  until  after  the  physieal  examina- 
tion, ami  until  after  any  supph^nientary^  e\itlence  has  Ix-en  elieited 
in  the  way  of  answers  to  questions  which  may  be  suggested  by  the 
examination. 

A  knowledge  of  the  normal  eon^litions  h  essential,  if  the  value  of 
tfie  abnormal  symptoms  is  to  Ik*  e^iinatect  correctly. 

The  Address. — This  is  impurtant  not  only  as  a  matter  of  business 
but  as  showing  the  possible  effect  on  the  patienCs  health  of  a  healthy 
or  an  unhealthy  locality. 

nationality. — The  colore<l  race  is  especially  prone  to  fibroids. 
Cancer  Ls  seldom  foimrl  in  a  negress. 

Occupation* — Confinement  in  poorly  lighted  and  ventilated  work- 
gbopg^  long  working  hours,  heavy  lifting,  insufficient  focxl  and  pro- 
ved standing  on  the  feet  aggravate,  if  they  do  not  caus4%  pelvic 
^disorden^a  On  the  other  hand,  a  seilentary  life  with  no  real  exercise 
may  act  as  a  contributory  cause  of  j^Hdvic  tlisease. 

Age.— The  age  of  the  patient  suggests  the  sfx^cial  disturlmnces 
found  in  the  various  e|>ochs  of  life.  In  infancy  malfonnations  and 
inflammations  of  the  lower  genital  tract  are  to  Ix*  ex|XH'ted.  At 
ihiii  time  the  infections  are  generally  limited  to  the  vulva  and 
vagina,  and  tumors,  displacements,  and  traumatisms  seldom  exist. 
Vulvo>va^nitis  is  not  uncommon  in  little  girk. 


10  INTERPRETATION  OF  THE  CLINICAL  HLSTORY 

Failure  of  the  menses  to  appear  previous  to  the  sixteenth  year 
should  excite  no  apprehension ;  after  that  it  is  apt  to  indicate  under- 
development of  the  uterine  organs. 

During  the  period  of  sexual  maturity  nearly  all  of  the  lesions  of 
the  genital  organs  may  be  found.  The  effects  of  gonorrhea  are 
seen  most  often  between  the  ages  of  twenty  and  thirty.  Tumors 
of  the  breast  are  most  frequently  malignant  between  the  ages  of 
forty  and  sixty.  Under  the  age  of  thirty-five  a  large  alxlominal 
tumor  is  more  likely  to  be  ovarian;  after  that  age  it  is  more  apt  to 
be  a  uterine  fibroid. 

A  patient  suffering  from  uterine  hemorrhage  more  probably  has 
endometritis  or  a  polypus  if  under  twenty;  a  polypus  or  some 
condition  resulting  from  gestation,  from  twenty  to  thirty;  fungous 
endometritis,  polypus,  or  fibroids  from  thirty  to  forty ;  fibroids  and 
malignant  disease  from  forty  to  fifty.  After  fifty,  malignant 
disease  is  the  probability. 

Social  Condition. — Congenital  malformations  may  be  brought  to 
the  patient's  attention  for  the  first  time  after  marriage.  Certain 
inferences  may  be  drawn  from  the  single  or  the  married  state  of  a 
patient  as  regards  the  cause  of  menorrhagia  or  metrorrhagia,  as 
shown  by  the  tables  on  pages  137  and  139,  Chapter  X.,  also  as 
regards  leucorrhea,  as  found  on  pages  144-146.  Pregnancy  is 
always  to  be  considered  if  the  pati(*nt  is  not  a  virgin.  An  early 
question  as  to  the  patient's  social  stat(%  whether  single,  married, 
or  a  widow,  may  obviate  embarrassing  queries  as  to  sexual  re- 
lations and  may  throw  light  on  the  possible  causes  of  her  com- 
plaints. For  instance,  a  recently  married  woman,  always  a  sufferer 
with  dysmenorrhea,  finds  the  symptom  aggravated  and  unbearable 
since  her  marriage.  A  periodic  pelvic  congestion,  due  to  mal- 
position or  malformation  of  the  uterus,  has  been  accentuated  by 
the  congestion  which  attends  sexual  relations.  A  recently  married 
woman  complains  for  the  fii*st  time  of  smarting  on  urination,  and 
leucorrhea.  Suspicion  of  infection  with  the  gonococcus  at  once 
arises  in  the  physician's  mind.  The  possibility  of  pregnancy  or 
venereal  infection  should  never  be  lost  sight  of,  notwithstanding  the 
patient's  statement  that  she  is  single  or  a  widow,  great  caution  and 
tact  being  exercised,  however,  in  making  inquiries.  The  final 
question  as  to  the  truth  or  falsity  of  the  suspicion  should  be  left 
until  after  the  physical  examination  in  any  event,  and  in  many 


CHILDREN 


n 


not  Ix^  matle  at  all  witliout  causing  serious  and  unjustifi- 
able  trouble  in  the  family  of  the  patient. 

Dyspareunia.— Dyspareunia  dating  from  the  time  n{  marriage 
indi(*ates  smallneKs  of  the  introitus  vagime  or  uri'thral  earuiK'lt*, 
if  the  pain  is  at  the  Irx^ginnitig  of  t^oitus.  If  the  pain  is  ex[>prienceil 
after  the  penis  has  bet^n  introduceil  into  the  vagina  the  cause  is 
apt  to  be  pehie  inflammation  or  a  tender  cervix  or  ovary. 

Children.^SterUity.—Thv  absejiee  of  children  njay  Ix^  important, 
for  if  a  patient  has  been  married  many  years  and  has  not  been 
pregnant,  the  inference  is  that  the  cause  of  the  sterility  re^ts  with 
her  and  not  with  her  husband,  the  latter  bcnng  in  goal  health,  and 
we  may  expi^ct  to  find  some  underdevelopment  or  malformation 
of  the  sexual  organs.  If  there  is  any  doubt  as  to  the  husband's 
virility  a  i?peeimen  of  his  stamen  should  Ix?  examined  for  s[>erma- 
tozoa  before  subjecting  the  wife  to  gyiiecotogical  treatment. 
(See  Chapter  X,,  page  147.) 

Carcinoma  of  the  cervix,  common  in  parous  women,  is  rare  in 
nullipane,  wliereas  cancer  of  tlie  Ixxly  of  the  uterus  is  more  apt  to 
occur  in  wonim  who  have  not  lumio  children.  Coinplete  or  rela- 
tive st4?rility  is  often  found  in  women  suffering  with  fibroids. 

Numljer  of  Children, — Thi^  numlxT  of  children  a  woman  has  had 
is  important  lx*cauH<*  rhild-ix'aring  without  a  sufTieient  interval  of 
recuperation  tx'tween  the  labors  frequently  results  in  some  sort 
of  pelvic  ailment.  Therefore,  note  the  ages  of  the  children,  Th<* 
history  of  t»ach  ronfinement  is  <>f  the  gn^atest  ser\ace  in  determin- 
ing the  origin  of  a  i)elvic  inflammation,  a  niisptacement  of  the 
utt^rus,  or  lacerations.  A  difficult  forcefxs  delivery  followed  by 
fever  and  a  tetlious  convalescence  may  tncan  all  three,  though  not 
nec!€ssarily* 

Mwcarrmges  and  Aboriiom. — A  history  of  each  miscarriage  or 
abortion  should  be  secured  with  reference  to  the  birth  of  chiklren: 
if  before,  the  int»'rruption  of  labor  can  not  be  due  to  injuries  re- 
ceived at  labor;  if  subsequent  to  a  tliflicult  and  complicated  con- 
finement, an  abortion  may  well  be  cau.sed  by  the  lalx>r.  The 
probable  cause  of  an  abortion  in  the  patient's  estimation,  whether 
attended  by  hemorrhage  or  fever  and  how  long  the  patient  was 
confined  to  her  bed,  are  points  to  be  ascertained.  These  facts  often 
reveal  the  starting  point  of  an  attack  of  pelvic  inflammation »  or 
anemia  and  subsequent  debility  due  to  loss  of  blood.    If  rept*ated 


12  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

abortions  have  occurred  they  may  indicate  syphilis,  tuberculosis, 
or  a  deeply  lacerated  cervix. 

Family  History. — How  much  of  a  role  heredity  plays  in  the 
etiology  of  pelvic  disease  is  not  determined.  Cancer  and  tuber- 
culosis are  found  occasionally  in  members  of  the  same  family.  It 
sometimes  happens  that  several  sisters  will  all  have  a  similar  lesion 
of  uterine  underdevelopment.  I  have  seen  three  sisters,  each 
suffering  from  marked  pathological  anteflexion.  A  premature  or 
delayed  occurrence  of  the  menopause  is  frequently  a  family  charac- 
teristic. So  is  the  symptom  of  dysmenorrhea.  Family  history,  as 
a  rule,  does  not  have  an  important  influence  on  diagnosis. 

Previous  History,  on  the  other  hand,  is  of  great  importance.  We 
have  noted  how  an  abortion  may  be  the  starting  point  of  an  attack 
of  pelvic  inflammation  to  be  followed,  perhaps  years  later,  by  serious 
lesions  of  the  pelvic  organs.  So  a  history  of  *' inflammation  of  the 
bowels,"  without  assignable  cause,  may  mean  pelvic  inflammation, 
the  nature  of  the  treatment  employed  at  the  time  of  the  attack 
throwing  some  light  on  the  probable  diagnosis. 

An  attack  of  soreness  of  the  vulva  associated  with  a  purulent 
discharge,  with  or  without  smarting  on  urination,  may  well  mean 
gonorrhea. 

Adhesions  of  the  labia  minora,  and  of  the  prepuce  to  the  clitoris, 
and  even  imperforate  hymen,  may  be  caused  by  inflammation  of 
the  vulva  in  childhood  due  to  diphtheria,  scarlet  fever,  measles,  or 
gonococcus  infection.  Nocturnal  enuresis  is  caused,  sometimes, 
by  adhesions  of  this  sort.  Therefore,  when  possible,  the  mother 
of  the  patient  should  be  questioned  whether  her  daughter  had 
vulval  soreness  and  discharge  when  a  child. 

A  lack  of  control  over  the  bowels  when  loose,  during  the  months 
following  a  labor,  leads  us  to  expect  to  find  injury  of  the  sphincter 
ani,  also  inability  to  control  the  urine  when  standing,  or  on  laugh- 
ing and  coughing,  make  us  look  for  injury  of  the  vaginal  wall  and 
perineum  and  dislocation  downward  of  the  urethra. 

Injury  of  the  pelvic  floor  is  present  if  the  patient  complains  of 
the  noisy  escape  of  air  from  the  vagina  when  she  suddenly  changes 
the  position  of  her  boily,  or  strains. 

Constitutional  Diseases. — All  general  constitutional  diseases  have 
a  bearing  both  as  causative  agents  and  aggravating  influences  on 
pelvic  disordehs;  therefore  they  should  be  inquired  into  in  getting 


MENSTRl'ATION 


18 


the  historjv  It  5io  oftni  liappi'iLs  that  a  wdiiiaii  in  hrr  usual  good 
health  is  not  seriously  mcomnioclctl  l)y  a  pelvic  Ic^^ion  and  when 
pullc<l  down  by  a  long  illni's.s  Ls  overwhelnuul  by  uterine  .symptoms. 
The  physician  should  move  slowly  in  drawing  eonelusions  as  to 
eaui^?  and  eflfect,  and  also  in  judging  of  tlie  weight  to  tx*  attached 
to  the  uterine  lUsease. 

It  should  never  (>e  forgotten  that  the  wliole  is  greater  than  any 
one  part  and  that  general  eonstitutional  disea^ses  take  preeedence 
over  gynecological  affections.     It  is  the  sick  woman  we  are  to  treat. 

Chief  Complaint  and  Present  Illness* — It  is  very  easy  for  the  en- 
thusiastic six^cialist  to  [wmi  his  energies  to  the  making  of  a  new 
ostium  to  a  dist*ased  Fallopian  tulx',  or  to  the  resection  of  a  diseased 
ovary,  quite  forgetting  for  what  the  patient  consulted  him;  that 
lx*CAUse»  he  has  fouml  an  abnormality  of  the  pelvic  organs,  this 
must  of  nect\ssity  be  the  cause  of  the  symptonis.  He  loses  sight  of 
the  symptoms  and  doesn't  always  make  a  projKT  etfoil  to  relieve 
thein,  bcnng  leil  away  on  a  futile  hunt  for  anatomical  |>erfection. 
Note,  then,  your  [mtient's  chief  complaint,  and  whrti  ycfu  tuive 
finiiihed  with  the  case,  tuni  to  your  notes,  refresh  your  memory, 
and  see  whether  this  complaint  has  Imtu  relieved. 

The  duration  and  character  of  the  present  symptoms  should  be 
note^lt  such  a*^  pain,  leucorrhea,  ablominal  swelling,  ami  symptoms 
relating  to  the  lx)wels  or  bladder,  ami  do  not  slight  the  indications 
of  the  state  of  the  general  health  as  shown  by  the  amount  anil 
character  of  the  sk»t*p,  the  state  of  the  digestion,  and  the  strength  to 
accomplish  customary  tiaily  tasks. 

Menstruation. — Menstruation  may  Ix*  defined  as  a  disf*harge  of 
blcx)dy  fluid  which  takes  place  fron}  the  uterus  at  states  1  periods 
throughout  the  time  of  s*;\xual  activity  in  the  life  of  women.  The 
causation  of  the  discharge  is  still  in  iloubt. 

Frankel  (**Die  Function  des  Corpus  luteum/*  Arckiv  fur  Gyn.f 
LXVIII,,  11MB,  4liH)  considers  that  the  corpus  luteum  in  the  ovary 
lia:5  a  detennining  influence  on  menstruation.  It  is  plain  that  the 
ovaries  have  something  to  do  with  this  function  because,  when  they 
are  removed,  menstruation  ceases.  As  menstruation  occurs  only 
in  human  Ix^ings  and  some  of  the  higher  ai>es.  it  is  difficult  to  s<*ttle 
tbt*  relation  of  menstruation  tt)  ovulati<>n  and  to  the  normal  or 
abnormal  corpus  lutetmi  by  aTiimal  exjxrimeijtation. 

The  mechanisni  of    menstruation  consists  of   a  dia{>etlesis  of 


14  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

blood  through  delicate  capillaries,  newly  formed  in  a^  thickened 
and  congested  endometrium,  the  vessels  for  the  arterial  supply 
being  more  capacious  than  those  for  the  venous  return.  Some  of 
the  capillaries  rupture  and  the  blood  flows  out. 

The  flow  at  first  is  mucus  streaked  with  blood,  during  the  height 
of  menstruation  it  is  blood  mixed  with  a  little  mucus?,  and  toward 
the  end  it  becomes  more  mucous  in  character.  Menstrual  blood 
is  dark  in  color,  alkaline  in  reaction,  and,  because  of  the  mucus  it 
contains,  does  not  clot  unless  the  mucus  hapfx^ns  to  be  deficient. 
The  mucus  renders  it  more  watery  than  ordinary  blood.  It  has 
a  peculiar  odor  given  to  it  by  the  sebaceous  glands  of  the  vulva 
which  are  especially  active  during  menstruation. 

Puberty. — The  average  age  at  which  menstruation  is  established, 
in  temperate  climates,  is  fourteen  years.  Variations  of  a  year  or 
two  from  this  type  occur  within  normal  limits.  It  occurs  earlier 
in  the  city  girl  who  is  subjected,  perhaps,  to  intimate  association 
with  the  other  sex  and  to  sexual  temptations,  than  it  does  in  the 
country  girl,  or  in  a  girl  carefully  brought  up  in  comparative  seclu- 
sion. This  rule  applies  to  the  lower  animals.  If  a  bull  is  placed 
in  the  pasture  with  a  herd  of  heifers,  heat  appears  earlier  in  the 
heifers  than  it  does  when  they  arc  segregated.  In  women  of  strong 
sexual  passion  the  function  of  menstruation  is  established  earlier  and 
lasts  longer  than  conmion. 

The  discharge  of  ova  from  the*  Graafian  follicles  of  the  ovary 
has  been  known  to  take  place  before  menstruation  is  established, 
and  it  may  continue  after  the  nK^nopause.  The  functions  of 
menstruation  and  ovulation  are  not  directly  dependent  one  on  the 
other,  but  both  appear  to  Ix*  governed  by  the  same  portion  of 
the  sympathetic  nervous  system.  Cases  of  precocious  menstrua- 
tion are  occasionally  reported,  and  it  has  been  known  to  occur  as 
early  as  a  f(»w  days  after  birth.  There  are  many  cas(^s  on  record 
of  menstruation  at  a  few  weeks  or  months  of  age.  Development 
of  the  external  genital  organs  and  the  breasts,  increase  in  Ixnly 
size,  and  often  the  growih  of  hair  on  the  pul>es  goes  with  precocious 
menstruation.  The  diagnosis  is  not  established  unless  the  loss 
of  blood  Recurs  at  monthly  interv^als  and  a  physical  examination 
of  the  child  shows  evidences  of  i)remature  development. 

It  is  imusual  for  m(»nstruation  to  Ix^  established  before  the  twelfth 
year.     On  the  other  hand  its  appearance  is  seldom  delayed  beyond 


MENSTRUATION 


15 


)m. 


the  eighteenth  year.  A  case  is  on  record,  however,  where  a  woman 
married  at  thirty-four,  menstruated  for  the  first  time  at  forty-five, 
and  bore  a  child  at  ffirty-.six.  According  to  the  invi^stigation  of 
I{08si-I)oria,  an  Italian  jihysiclan,  who  recorded  the  data  in  over 
thirty  tlionsand  women,  delayed  meni^truation  ^ovs  hand  in  Iiand 
with  fML*lvic  di^ase.  He  found  39.21  per  cent  of  pelvic  malforma- 
tions bi  women  who  had  not  menstruated  until  twenty  years  or 
over. 

The  normal  rhythm  of  meni^truation  is  a  lunar  month  of  twenty- 
eight  daj's.  A  woman  nmy  enjoy  perfect  health  in  every  respect 
and  yet  vary  many  days  from  the  normal  rhythm.  Many  women 
menstruate  every  three  weeks,  otiiers  every  five  weeks,  with  perfect 
rt^pilarity.  In  getting  a  history  of  the  menstrual  function  it  is 
nect^<<ary  to  specify  the  rhythm  of  the  flow  as  well  as  the  regularity. 
It  is  well  to  rememlx'r  alsfj  that  some  women  are  ix^gular  at  times 
and  irregular  at  other  timet?. 

The  duration  of  the  flow  i^  from  four  to  seven  days.     Here  also 

variation  within  normal  limits  of  two  days  either  way  is  to  be 
e<l,  TIk'  greatest  amount  of  blootl  is  lost  in  the  first  two  days. 
A  discharge  of  mucus  before  and  after  the  How  is  common.  The 
average  amount  of  |j|ood  lost  at  a  single  mt^nstruation  is  fi'om  four 
to  six  ounces.  It  is  imprartical>le  to  measure  this  exactly  and  we 
are  forced  to  resort,  to  the  inexact  method  of  counting  the  number 
of  napkins  u^mxI.  As  the  napkins  vary  in  size,  are  used  to  the 
pouit  of  saturation  by  some  women  and  barely  stainc><l  by  others, 
no  definite  infurmatinn  can  h»  obtained.  Intjuiry  on  these  points, 
however,  will  give  the  i>hysi(*ian  an  approximate  estimate  which 
uld  b**  rtvonk*<l  in  detail  in  his  not»'s,    Aliout  two  well-saturated 

pkins  a  day  may  lie  cdnsiili^red  as  U^ing  normal. 

\Miether  menstruation  is  excessive  in  any  given  case  depends  in 
m  certain  measure  on  the  physi(]ue  uf  the  patient;  a  full-blooded, 
plethoric  woman  may  menstruatr  right  or  nine  days,  using  three  or 
more  well- saturated,  large  napkins  a  day;  while  an  aninnicj  thin 
woman  may  be  deprinsscnl  by  the  amount  of  blood  lost  in  a  i>eriod 
of  four  days,  using  two  najikins  a  ilay. 

The  character  of  the  flow  is  of  iini)ni1ance.  Note  clotting,  an 
acid  reactibn,  a  bright  arterial  color,  and  any  change  in  odor* 

Attendant  disturbances  t»f  tither  functions,  iM'fore,  during,  and 
menstruation,  such  as  nausea,  headache,  depression  of  spirits. 


16  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

variations  in  the  action  of  the  bowels  or  bladder,  are  very  commonly 
observed,  and  should  be  chronicled. 

Menstruation  is  generally  attended  with  a  greater  or  less  degree 
of  a  sense  of  fulness  and  weight  in  the  region  of  the  pelvis;  often- 
times a  certain  amount  of  pain  is  to  be  considered  as  not  abnormal. 
The  menstrual  period  is  a  time  of  instability  of  the  circulation  and 
of  the  nervous  system.  The  body  temperature  is  slightly  elevated, 
the  thyroid  gland  is  enlarged,  and  the  tonsils  and  vocal  cords  may 
be  swollen  so  as  slightly  to  impair  the  singing  voice;  so  also,  in  some 
cases,  there  are  salivation  and  swelling  of  the  mucous  membrane 
of  the  turbinate  bones  at  this  time.  There  is  increased  vascular 
tension  and  increased  secretion  of  the  s^eat  glands  and  of  the 
sebaceous  glands,  especially  those  of  the  external  genitals.  Some 
women  arc  affected  by  skin  diseases  at  their  catamenia,  notably 
herpes,  or  small  macular  ecchjTuoses  about  the  flexures  of  the 
elbows  or  knees. 

A  rhythmical  wave  of  all  the  physiological  processes  has  been 
demonstrated  by  Von  Ott.  The  greatest  activity  is  manifest  just 
before  the  appearance  of  the  flow,  showTi  by  increase  of  muscular 
strength,  tendon  reflexes,  lung  capacity,  and  heat  production.  The 
least  activity  is  during  the  flow,  the  lowest  point  Ijeing  reached  on 
the  fourth  day.  There  is  a  slight  reaction  in  the  week  following  the 
cessation  of  the  flow,  an  intermenstrual  equilibrium  of  two  or  three 
days,  to  be  followed  by  a  gradual  rise  to  a  maximum  two  days  be- 
fore the  next  flow,  and  so  on  from  month  to  month. 

The  Mefio pause. —The  climacteric  or  cessation  of  the  flow  usually 
occurs  from  the  forty-fifth  to  the  fiftieth  year,  the  discharge  at 
this  time  becoming  less  and  less  in  amount  and  of  irregular  occur- 
rence, gradually  stopping  altogether  in  from  six  months  to  two 
years.  Menstruation  may  stop  short  without  any  period  of  irregu- 
larity and  there  may  be  no  disturbance  of  the  ner\^ous  system, 
although  the  latter  is  more  common. 

If  a  woman  begins  to  menstruate  early  the  menopause  is  apt  to 
be  late,  and  vice  versa.  It  is  a  family  characteristic  sometimes  to 
have  the  menopause  early  or  late.  In  cas(»  of  fibroid  tumors  of  the 
uterus  the  menopause  is  commonly  delayed  until  the  fiftieth  year 
or  later,  and  in  subinvolution  and  chronic  metritis  the  menopause 
comes  late. 

Vasomotor  disturbances  are  to  be  looked  for  during  the  meno- 


MENSTRUATION 


17 


pause.  The  monthly  rh jlhm  which  hss  existed  since  the  fourteenth 
year  ia  to  be  done  away  with,  the  sexual  organs  are  to  atrophy  and 
bec*onie  funetionless*  If  the  woman  Is  in  perfect  health  we  shall 
cpect  nature  to  aeeompUsh  the  ehange  gradually  an  it  was  estab- 
shed,  and  withotit  an  upsetting  of  the  general  health.  Too  often, 
for  one  reason  or  another,  the  health  is  not  rugged,  then  ensue  hot 
flashes,  sweating,  palpitation,  headaches^  nervous  irritability,  and 
derangements  of  function  in  many  organs,  more  especially  those 
most  closely  controlletl  by  the  sympathetic  nerv'ous  system. 

It  is  a  n)istake  to  consider  uterine  hemorrhage  as  a  part  of  the 
normal  menopause.  It  seklom  occurs  unless  there  is  a  definite  local 
cause  in  the  shajx*  of  a  fibroid  tumor,  a  cancer,  chronic  subinvolu- 
tion with  hyperplastic  endometritis,  misplacenient  of  the  uterus, 
or  other  lesion.  Thc^se  uterine  diseases  may  have  eauscil  no  symp- 
toms, though  existent  for  many  years.  Search  should  always  be 
made  for  them. 

The  Atrophic  Changes  in  the  Genital  Organs  and  the  Body  Altera- 
turns  of  Uw  Men4}pause, — The  changes  in  the  genital  organs  and  in 
the  body  consist  of  ia)  shrinking  of  the  uterus  in  size.  The  nms- 
cular  tissue  becomes  less  thick  and  gradually  the  uterine  cavity  is 
shortenf*il  or  even  obliterateil,  the  mucosa  IxToming  thinnest  and 
3e  glands  reduced  in  nurnbi»r.  Tlie  epithelial  cells  grow  smaller 
ftd  lo^  their  cilia.  The  vaginal  portion  of  the  cervix  shrinks  and 
dots  not  project  into  the  vagina,  ih)  The  vagina  is  shortened  and 
narroweil  and  its  walls  lose  their  elasticity  and  the  mucous  mem- 
brane its  rugae,  (c)  The  ovarirs  siirink  to  sniall  knobs  of  fibrous 
tii^ue,  the  Graafian  follicles  disappear,  and  the  Fallopian  tubes 
l»*.*come  mere  cords,  (d)  The  fat  disai^iw^ai-s  from  the  \iilva,  the 
labia  majora  become  flabby,  and  the  mons  veneris  loses  its  prom- 
ioeoee.  (c)  The  pubic  hair  turns  gray  after  the  hair  of  the  head 
has  lost  iij^  colon  (/)  The  breasts  also  atrophy  and  become  flabby, 
and  iQ)  the  Ixniy  weight  is  increased. 

Tlic  menstrual  flow  may  cease  prematurely  at  an  early  age,  even 
B»  eariy  as  the  twenty-fourth  year,  the  causes  being  general  or  kwal. 
As  Uy  the  general  causes  not  much  is  known  bt^yond  that  they  have 
to  do  irith  the  nutritive  and  vascular  systems. 

The  local  causi's  an^  disea!*L\s  which  destroy  tlie  ovaries,  as  chronic 
infective  inflammation,  anti  removal  of  the  o varices  by  oiK^ation. 
It  is  worthy  of  Remark  that  when  functionating  ovaries  have  been 

2 


18  INTERPRETATIOX  OF  THE  CLINICAL  HISTORY 

removed  the  distressing  nervous  symptoms  of  the  climacteric  are 
much  more  severe  than  when  the  menopause  occurs  with  the 
ovaries  in  place.  (The  menopause  is  discussed  fully  in  Chapter 
XXIX.) 

Vagmal  Discharge. — ^Any  discharge  from  the  vulva  is  popularly 
referred  to  as  leucorrhea  or  whites.  A  certain  amount  of  moisture 
is  normal  and  is  made  up  of  the  secretions  of  the  sebaceous  and 
sweat  glands  of  the  \'ulva,  the  lubricating  mucus  secreted  by  the 
glands  of  Bartholin  Ijnng  m  the  posterior  portion  of  the  labia  majora, 
— most  active  during  times  of  sexual  excitement, — and  by  the 
secretions  of  the  uterus. 

The  vagina  has  no  secretion  proper  and  no  glands,  the  vaginal 
secretion,  scM*alled,  being  that  {X)ured  out  of  the  uterus  together 
with  epithelium  and  bacteria  made  acid  by  a  bacterium  which 
flourishes  in  the  vagina  under  normal  conditions.  The  fluid  is 
milky  and  small  in  amount.  The  secretion  from  the  cer\ax  is 
tenacious,  transparent,  and  thick:  that  from  the  endometrium  of 
the  uterine  ca\ity  is  clear,  transparent,  and  thin.  Both  have  an 
alkaline  reaction. 

Skene's  glands  at  the  orifice  of  the  urethra  also  secrete  a  mucus, 
which  Ls  thought  to  protect  the  meatus  urinarius  during  coitus. 
Under  normal  conditions  the  combined  discharge  should  not  soil 
the  clothing  except  just  before  and  just  after  the  menstrual 
periods,  when  all  the  secretions  are  increased  in  amount  and  may 
necessitate  wearing  a  napkin. 

Abnormal  constituents  of  the  vaginal  discharge,  such  as  pus  or 
blood,  should  be  noted,  also  a  bad  odor  or  irritating  qualities.  (This 
subject  is  discussed  at  greater  length  in  Chapter  X.,  page  143.) 

Pain. — Pain  in  gynecological  affections  is  generally  situated  in 
the  inguinal  and  lumbro-sacral  regions. 

Backache. — Backache  is  not  characteristic  of  any  special  uterine 
disease  and  it  may  have  no  relation  at  all  to  the  pelvic  contents. 
All  we  can  say  is  that  it  is  very  often  present  in  women  suffering 
with  gynecological  diseases.  Backache  is  very  common  in  women 
between  the  ages  of  thirty  and  fifty  who  are  in  a  nervously  run- 
down condition.  One  sort  of  backache  due  to  sacro-iliac  sub- 
luxation  as  described  by  Joel  E.  Goklthwait  (Boston  Med.  and 
Surg,  Journal,  1905,  \'ol.  152,  593)  must  be  differentiated  from 
rheumatism  of  the  muscles  in  the  lumbo-sacral  regions.    The  sacro- 


PAIN 


19 


I 


I 


■    it 


iliac  articulations  are  true  joints  and  there  is  inereased  mobility 
in  them  as  well  as  in  the  symphysis  pul>i8  in  women  during  preg- 
nancy and  during  menstruation.  In  certain  women,  espoeially 
thosic  ha\ing  spinal  em*vature  who  are  the  \it'tims  of  subliLxation, 
only  one  sacro-iliae  joint  is  tender  to  pressure,  and  the  displace- 
ment is  the  cause  of  l>ackaehe  as  well  as  referred  pains  in  the  hip, 
leg,  and  ankle  on  the  same  side  as  the  loose  joints  caused  by 
pressme  on  the  sciatic  nerv^e.  These  symptoms  am  not  limitM  to 
the  time  of  pregnancy  and  labor,  tliough  exaggerated  tlien.  The 
symphysis  pubis  is  generally  a  loose  joint  also  in  these  cases  and 
may  be  painful  to  the  touch,  especially  < luring  menstraation.  The 
mobility  and  tenderness  of  all  tliree  joints  shoulii  be  tested  in  any 
ease  of  bac*kache. 

Mw'icular  rheumatism  is  detected  by  tenderness  on  pressure  of 
the  following  muscles: — the  erector  spinie, — the  longissiruiLS,^ 
the  E^acro-lumhalia,  or  the  quadratus,^and  by  pain  caiisi»d  by  the 
tiise  of  any  of  these  muscles.  When  a  patient  with  Imn bo-sacral 
rheumatism  startjs  to  straighten  up,  there  is  great  i)ain,  which 
aijates  after  a  few  niinytes*  ysr-.  A  [>atient  with  thisaffcxvtion  sits 
or  Men  preferably  with  the  bod}*  bent  forward. 

Coccyijodymn  is  a  painful  aff^rtion  of  the  coccyx  and  is  charac- 
terized by  pain  Ix'tween  the  folds  of  the  buttocks  and  by  tenderness 
on  pressurt*  applietl  to  the  tip  of  the  cocx'yx.     (See  jiage  159,) 

Pain  in  the  grains  m  common  in  uterine  dist»ases.  In  acute 
inflammation  it  is  generally  j»ronniurced.  es[iefialty  wlirji  the 
eum  is  involved.  In  chronic  uterine  dis^'ase  it  may,  or  it 
may  not,  be  presi»nt.  If  existent  it  is  generally  a  dull,  continuous 
pain.  If  on  the  right  side  it  is  to  be  cUfferentiated  from  the  sharp 
micrmittent  pain  of  appendicitis,  and  the  pain  and  tenderness  on 
deep  pressure  in  this  situation,  in  cases  of  uterine  disease,  are,  as  a 
rule,  lower  down  than  in  apiDendicitis. 

4  ftearing-dovm  feeling,  or  o  sense  of  umfjht  In  the  jH'hns,  is  a  very 
fretjuent  complaint.  If,  in  answer  to  your  question,  the  |>atient 
states  that  she  has  pa'm,  ascertain  where  it  is  situated;  thc^  point 

greatest  intensity;  whether  it  is  constant  or  intermittent,  fixed 
tir  rafliating;  what  sort  of  a  pain,  dull,  sharp,  or  stabbing.  Describe 
it  in  the  patient's  own  words  as  far  as  possiI>le.  The  relation  be- 
tWfCQ  the  pain  and  menstruation,  if  any,  shoulii  l>e  inquired  into; 
ilso  the  rffect  of  exercise.    The  situation  of  the  pain  often  shows 


20  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

the  nature  of  the  lesion.  Thus,  pain  in  the  sacral  region  may  mean 
rectal  disease,  and  pain  above  the  pubes,  disease  of  the  bladder. 
This  is  not  always  the  case,  as  is  shown  by  the  fact  that  disease  of 
one  ovary  is  often  referred  to  the  opposite  side  of  the  abdomen, 
therefore  we  must  be  on  the  lookout  for  referred  pain. 

Abdominal  swelling,  indicating  a  tumor  of  any  sort,  is  to  be  asked 
for.  If  present,  when  was  it  first  noticed, — what  is  its  exact  situa- 
tion,— has  it  increased  in  size  since  it  was  first  detected,  and  if  so 
how  much  and  how  fast, — whether  or  no  there  has  been  pain  in  the 
swelling  or  tenderness  on  pressure. 

In  the  case  of  a  suspected  ovarian  tumor,  ask  whether  there  has 
been  a  loss  of  flesh  about  the  chest  and  shoulders  coincident  with 
the  increase  in  the  size  of  the  abdomen.  The  occurrence  of  jaundice 
in  connection  with  a  tumor  in  the  upper  abdomen,  as  indicating 
disease  of  the  liver  or  gall-bladder,  is  to  be  noted,  also  the  relation 
between  a  tumor  in  the  flank  and  impaired  function  of  the  kidneys, 
I)ointing  toward  tumor  of  the  kidney. 

A  swelling  of  the  abdomen  in  a  woman  of  child-bearing  age  may 
mean  pregnancy,  however  improbable  such  a  diagnosis  may  seem, 
— therefore  ask  always  the  date  of  the  last  menstruation.  Bear 
pregnancy  in  mind  even  if  the  probable  diagnosis  is  fibroid, 
ovarian  cyst,  or  other  tumor;  pregnancy,  intra-  or  extrauterine, 
may  coexist  as  a  complicating  condition.  It  has  happened 
several  times  in  the  author's  experience  that  a  surgeon  of  high 
reputation  has  discovered  pregnancy  in  the  course  of  an  abdom- 
inal operation,  undertaken  for  "abdominal  tumor"  without  a 
more  exact  diagnosis. 

Bladder  Symptoms. — The  fact  should  be  borne  in  mind  that 
women,  as  a  rule,  urinate  at  less  frecjuent  intervals  than  men.  In 
obtaining  a  history  it  is  important  to  inquire  as  to  the  patient's 
habit  as  regards  micturition,  lx.»fore  drawing  conclusions  as  to  the 
abnormality  of  the  symptoms.  The  occurrence  of  bladder  affec- 
tions is  rarer  in  women  than  in  men. 

Freciuency  of  urination  on  standing  or  exertion,  with  inability 
to  holtl  the  urine,  may  mean  a  stone  in  the  bladder,  whereas  constant 
dei?ire  to  urinate  may  l>e  due  to  cystitis  or  urethritis;  therefore  it  is 
necessary  to  inquire*  whothcT  the  frecjuency  is  by  day  or  by  night. 
Smarting  on  urination  indicates  some  irritation  of  the  vulva  or 
urethra.     Inability  to  control  the  urine  at  all  shows  a  fistula  from 


THE  BOWEIiJ 


21 


I 


the  hlatldcr  into  i\w  vagina,  viihvr  rlircc*tl>%  or  by  way  of  the  uterus; 
f  fK>wer  over  the  bladder  on  laughing,  sneezing,  and  coughing 
means  lack  of  su|>i>ort  to  l)!adder  or  urethra  from  injury  to  the 
fX'lvie  floor  or  to  the  anterior  vaginal  wall  These*  are  .samples  of 
the  class  of  facts  which  should  b**  h^amed.     (The  subject  is  con- 

f^dertn:!  at  length  in  Chapter  X,,  page  151.)  Ask: — How  <rften  the 
patient  urinates?  How  freciuently  at  night?  How  much  ymin  in 
the  act?  When  the  pain  is  most  intense?  How  long  the  |)aiii 
laM*^?  Is  it  possible  to  control  the  urine  when  the  desire  to  urinate 
<x*curs?  Is  the  trouble  getting  better  in-  worse?  Is  it  affectvHl  by 
meni^niation?  Is  it  Ix'tter  or  worse  when  the  l>owels  are  free? 
Wlien  did  the  liifficuhy  ix^gin?  What  is  the  supixjsable  cause?  Is 
the  trouble  the  same  now  as  at  the  beginning?  WTiat  treatment,  if 
y,  has  lMx»n  ustni? 

The  Bowels* — Constipation  is  the  rule  in  a  large  proportion  of 
women  suffering  with  gynecological  affections.  At  least  a  third  of 
all  such  patients  are  so  affected,  according  to  reliable  statistics.  The 
statement,  however,  that  a  woman  is  constipated  does  not  descrilx* 
the  condition  with  sufficient  minuteness.     Many  women  pay  little 

]^tention  to  their  lx)wels^  considering  ilefecation  as  a  troublesome 
fimctioQ  to  be  disregardtnl  a.s  long  as  |>ossible.  Therefore,  it  is 
neceflsary  to  make  careful  iniiuiries  to  deterniine  tliat  constipation 
really  exists.  The  amount  of  ft*cal  matter  passed  depends,  of  course, 
on  the  amount  and  character  of  frnxl  ingested.  People  of  irregular 
habits  as  regarris  their  fooil  shoul<l  Ix^  expectetl  to  }>ass  a  variable 
amount  of  fecal  matter;  four  to  eight  ounces  is  said  to  be  the 
normal  amount  passcnl  in  twenty-four  hours  if  the  patient  is  Ii\ing 
on  a  mixed  (Het.  The  amount  is  more  if  the  diet  is  vegetable  rather 
than  if  animal.  Habits  of  a  lifetime  have  a  controlling  influence  on 
defecation,  and  a  person  may  evacuate  the  bowels  regularly  every 
other  day  or  twice  a  tlay  and  yet  Ix*  within  the  limits  of  the  normal. 
We  must  inquire  whether  the  bowels  move  regularly,  i\€\,  without 
raetlicine,  enema,  or  artificial  aid  of  any  kind,  at  statcM:!  periods  of 
time,  and  what  those  times  are:  whethei*  th<*  action  is  full,  or 
ty,  and  the  stools  solid,  semisolid,  or  liquid:  whether  there  is 

^fiajii  on  defecation  at  the  time  (hemorrhoids)  or  lasting  after  the 
mo^x^ment  (fissure  of  the  anus);  whether  the  stools  am  ribbon- 
like (iftricture  of  the  i^ctum);  whether  offensive  (decomposition); 
containing  blooti,  mucu*s,  or  pus  (hemorrhoids  or  fistula  in  ano); 


22  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

whether  there  is  escape  of  gas  involuntarily  (some  injury  of  the 
sphincter,  or  fistula  in  ano). 

In  some  cases  of  injury  of  the  pelvic  floor  the  patient  finds  that 
the  only  way  she  can  evacuate  the  rectum  is  by  making  digital 
pressure  in  the  vagina.  Prolapse  of  the  rectum  on  straining  at 
stool  is  to  be  borne  in  mind  in  getting  the  history. 

Inquiry  should  be  made  as  to  the  length  of  time  constipation  has 
existed,  whether  it  is  habitual  or  intermittent,  and  whether,  in  the 
patient's  mind,  there  is  any  assignable  cause.  The  physician  should 
consider  a  pelvic  tumor,  rupture  of  the  pelvic  floor,  a  stricture,  or 
malignant  disease  of  the  intestine  as  possible  causes  of  constipation. 
(See  Chapter  X.,  page  156.) 

Present  Illness. — Under  this  heading  we  group  together  the 
symptoms  whi(»h  go  to  make  up  the  complaint  for  which  the  patient 
consults  the  physirirfn.  They  consist  of  the  data  as  to  the  functions 
of  the  different  organs.  Aj)petite,  digestion,  and  sleep  receive  con- 
sideration in  the  detail  justified  by  their  importance  in  any  given 
case,  also  any  symptoms  indicating  derangement  of  the  heart, 
lungs,  kidneys,  or  other  organs. 

\'ariations  in  the  body  w(^ight  are  important  as  showing  changes 
in  the  nutrition.  Other  things  bcnng  e(iual,  a  greater  weight  shows 
increased  vigor  and  strength;  such  a  statement  being  susceptible 
of  modification  in  the  case  of  very  fat  people. 

In  this  portion  of  the  history  the  physician  has  an  opportunity 
to  show  his  ability  as  an  internist  and  by  his  knowledge  of  the 
science  and  art  of  medicine^  to  ke(»p  his  patient,  if  passible,  on  the 
main  line  of  practice  instead  of  shunting  her  on  to  the  sidetrack  of 
sp<»cialism. 

It  is  always  wise  to  note  the*  exact  date  of  the  last  menstruation 
before  finishing  the  history.  A  habit  of  doing  this  will  go  a  long 
way  toward  preventing  awkward  mistakes. 

Finally,  as  a  matter  of  record,  make  a  memorandum  of  the 
patient's  peculiarities  of  form  and  figure. 


CHAPTER  IV 


THE  PHYSICAL  EXAMINATION 


r  The  preparation  of  the  pnfient*  p.  ^. 

II.  The  preparation  of  the  examining  table,  p,  520.  Cure  of  the  instni- 
ments.  with  list  of  a  full  kit,  p,  ^H. 

III.  The  examination:  1.  Preparation  of  the  physician  tmd  plaein^  the 
patient  on  the  table,  p.  31;  The  dor$;al  (Kisitiiin,  p.  :13.  ^.  fn!!»p*xlioti  of 
llie  e%temaJ  genilalH,  p.  S3.  S.  I'aljjiition.  p.  114:  (a)  Ttie  vaginal  touch, 
p.  $4;  (h)  The  (x>mbined  vaginal  and  atxluminal  touch,  p>  tin. 

Having  taken  the  histon'  as  outlined  in  the  prccetling  chapter, 
the  next  prwetluir  is  the  physical  examination.  It  is  nut  neees- 
Hary  to  follow  exactly  the  same  routine^  in  ul!  eases:  iievertheleHs 
it  y  mottt  et^eential  to  have  a  definite'  syslein  ami  tt»  [inH't^nl  areonl- 
tng  to  it  in  all  but  exceptional  instances.  iK^cause  in  this  way,  and 
in  thi^  way  only,  are  Rvurces  of  error^  the  oniissinn  of  important 
9tgns,  reduced  to  a  mininiunj. 

Firj:t  let  us  consitler  L  the  pre/ttiratif^n  of  the  jKitimt,  then  IL  the 
preparatitm  of  the  examininff  tahle  and  the  instrumvnt^,  and  lastly 
HI.  the  examination  itself. 

So  much  does  a  go«>d  diagnosis  depend  on  careful  preliminaries 
and  on  a  nmltitude  of  little  things  that  no  apology  is  necessary  for 
the  space  <levote<l  to  them. 


L  THE  PREPARATION  OF  THE  PATIENT 

It  is  absolutely  essential  that  the  rectum  should  be  empty  in 
nnler  thai  the  |>hysician  may  make  a  satisfactory  bimanual  ex- 
aniination,  also,  in  the  ca*^  of  alKiominal  [>alpation.  if  the  Ix^vels 
are  distendtn:!  by  feces  or  gas  the  ability  of  the  examiner  to  appn- 
ciate  the  condition  of  the  alxlominal  contents  will  l^e  interfeix*il 
with.  Then^fon*  the  (mtient,  if  there  is  inY'd  and  if  time  serves, 
HhouJd  Ix*  instructs!  to  take  a  catharlie  thi^  day  before  the  exam- 
ination or  an  enema  immediately  lx»foi-e, 

23 


24  PHYSICAL  EXAMINATION 

If  a  patient  presents  herself  with  the  statement  that  the 
bowels  have  not  moved  for  several  days  it  is  better  not  to 
make  an  examination  until  they  are  solvent,  except  in  cases  of 
emergency. 

Unless  there  is  some  suspicion  of  disease  of  the  urinary  organs 
the  bladder  is  to  be  emptied  just  before  the  examination.  In 
certain  urinary  cases,  where  it  is  desired  to  obtain  a  catheter  speci- 
men of  urine  at  the  examination,  the  patient  should  be  asked  not 
to  empty  her  bladder  before  the  examination. 

As  a  rule  it  is  better  to  have  no  douche  or  special  wash  given 
before  the  examination,  because  the  examiner  wishes  to  form  an 
opinion  as  to  the  character  of  the  discharge,  if  present.  It  is  a 
simple  matter  for  him  to  wipe  away  the  discharge  later  with  sterile 
cotton  or  some  antiseptic  solution. 

The  most  important  matter  in  connection  with  the  preparatory 
treatment  of  the  patient  and  the  one  most  often  overlooked  is  the 
loosening  of  all  constricting  clothing  about  the  waist.  Simply  to 
loosen  the  corsets  and  leave  the  drawers  buttoned  about  the  waist 
is  not  sufficient.  So  often  women  come  to  the  examining  table 
with  corsets  and  skirts  loosened,  and  investigation  reveals  one  or 
two  tight,  constricting  bands  still  left.  Closed  drawers  should  be 
removed.  The  union  suit  is  a  foe  to  an  accurate  diagnosis  and 
should  be  removed.  If  the  patient  considers  her  condition  of 
ill  health  important  enough  to  consult  a  physician  she  should  be 
ready  to  offer  no  hindrance  to  a  proper  examination. 

With  any  encircling  girdle  about  the  upper  abdomen  it  is  mani- 
festly impossible  to  compress  the  abdominal  walls  and  to  palpate 
the  contents  of  the  abdomen  and  pelvis.  Such  palpation  is  difficult 
enough  with  all  conditions  favorable,  therefore  do  not  handicap 
it  by  omitting  to  have  all  clothing  loosened. 

If  the  patient  is  in  bed  she  should  be  prepared  by  having  her 
put  on  a  fresh  pair  of  stockings.  Should  the  Sims  position  be 
used  an  extra  towel  will  serve  for  covering  the  right  thigh. 

Much  depends  on  the  physician's  tact  and  the  manner  in  which 
he  goes  about  the  preparation  for  the  physical  investigation. 
Women  do  not  mind  an  examination  which  they  consider  necessary 
if  the  physician  shows  proper  consideration  for  their  feelings  and 
knows  how  to  go  about  the  examination.  If  the  matter  is  treated 
as  disagreeable  and  to  Ije  put  through  as  quickly  as  possible,  the 


PREPARATION  OF  THE   PATIENT 


25 


I 


I 


» 


result  is  apt  to  be  that  th*^  |i]iyj*ieian's  framr  of  uhikI  will  Ir  rc- 
flwttil  in  thf  patient  and  slic  will  tx^  ill  at  viisi*  and  consequently 
will  not  give  herself  up  to  the  investigation^  not  relaxing  the  al> 
(ioniiual  muscles  and  thus  limiting  tlie  fai'ts  which  may  be  gleauetl 
through  the  tactile  sense. 

The  patient  shoulil  lx»  made  to  fei*l  that  the  examination  is  to 
be  conducted  with  as  little  pain  and  discomfort  as  is  possible*  and 
thai  this  is  an  imixirtant  consideration  to  the  exaoiiner.  8he  may 
be  told  a  fact  too  often  lost  sight  of,  that  pain^  caused  by  roughness 
or  vigorous  handlings  makes  unconscious  resistance  and  rigidity 
of  the  abdominal  nmscles,  then^by  dulling  the  sense  of  touch  in 
the  doctor's  liands  antl  jjreventing  him  from  reaching  dee{>lying 
f?tructur€?s— conseciuently  the  examination  is  less  successful. 
Often  it  is  inatlvisable  to  make  a  thoroiif^h  hivestigation  and  a 
complete  diagnosis  at  one  sitting.  Sometimes  if  is  necessary  to 
examine  the  patient  on  several  <hfferent  ot^casions  before  all  the 
conditions  have  been  fomid  favorable  anil  all  the  facts  have  been 
brought  out.  Therefore  do  not  be  Ird  to  express  an  opinion  on 
the  ease  prematurely. 

In  the  ca^c*  of  young  girls  it  is  generally  mlvisable  to  use  an 
anes^thetic  before  making  a  kx-al  examination,  although  it  is  not 
always  nt*ceasar>%  nmch  depending  on  the  nervous  temjx'rament 
of  the  [latient.  In  making  an  examination  of  a  virgin  in  whom 
menstruation  has  bc*en  establish wl  an  anesthetic  is  seldom  requued 
if  gn^at  tact  ami  gentlen(*ss  are  used.  It  is  far  pref(i*able  to  make 
the  first  exaniination  without  ether  if  possilile,  bx*ause  often  facts 
ot  importance,  such  as  regions  of  tenderness,  brought  out  during 
the  examination,  are  lost  in  an  ether  examination,  to  say  nothing 
of  the  unfavorable  after-effects  of  the  anesthetic  on  the  patient. 
Should  the  first  investigation  show  the  need,  another  examination 
with  ether  can  Ix*  made. 

Too  much  can  not  Ix^  said  of  the  importance  of  the  tactful  hand- 
ling of  the  patient  prr^vions  to  the  examination.  To  see  one  skilled 
nurse  in  a  large  hospital  clinic  put  forty  women  on  the  table  for 
examination  during  the  course  of  an  afternoon,  no  complaints,  no 
nbjeetions,  and  one  following  the  other  with  military  prwision, 
iif  an  object  lesson  of  no  mean  value.  Few  nursc^s  accjuire  such 
experlnnsH,  and  to  few  is  it  neeilful.  Much  may  be  leamal  by 
\ying,  when  the  opportunity  offers,  the  way  it  is  done. 


26  PHYSICAL  EXAMINATION 

The  local  examination  should  be  made  during  the  intermenstrual 
period.  Only  in  the  case  of  hemorrhage  and  unusual  conditions 
is  it  necessary  to  examine  during  menstruation. 


II.  THE  PREPARATION  OF  THE  EXAMINING  TABLE  AND 
THE  INSTRUMENTS 

Some  hard  surface  on  which  the  patient  is  to  lie  is  a  necessity 
for  a  proper  examination.  A  soft  bed  or  couch  into  which  she 
sinks  takes  away  all  space  imder  the  buttocks  for  the  unused  fingers 
of  the  examiner's  hand  in  the  vaginal  examination.  Besides,  most 
bcKls  and  couch(»s  are  so  low  that  the  physician  is  in  an  uncom- 
fortable position  while  examining  and  so  many  of  his  muscles  are 
tense  that  he  can  not  concentrate  his  entire  attention  on  what  his 
fingers  are  feeling.  Furthermore,  with  the  patient  on  a  low  couch 
the  physician  cannot  get  his  eyes  on  a  low  enough  level  to  look  into 
the  vagina  unless  he  sits  on  the  floor  in  an  awkward  and  constrained 
position. 

A  tabl(^,  the  size,  shape,  and  height  of  an  ordinary  kitchen  table, 
is  on  the  whole  the  best  surface  on  which  to  put  the  patient.  Port- 
able or  fixed  supports  for  the  feet  are  a  useful  addition  and  also  a 
movable  slide  projecting  from  the  right-hand  lower  comer  of  the 
table  is  a  convenient  adjunct.  My  table  is  stoutly  built  of  walnut, 
has  large  casters  on  all  four  feet,  and  is  of  the  following  dimensions: 
— Length,  44  inches;  breadth,  24  inches;  height  at  bottom  end, 
33  inches;  height  at  head  end,  31  inches. 

It  is  to  be  not(Hl  that  th(»  foot  or  examining  end  is  higher  than 
the  head  end.  This  is  to  cause  the  viscera  to  gravitate  away  from 
the  pelvis  and  to  allow  of  more  pillows  for  the  head  without  in- 
clining the  trunk  downward  toward  the  pelvis. 

The  table  is  covered  with  a  hair  pillow  one  inch  thick,  encased 
in  a  dark-colored,  enamekHl  canvas  cov(t.  This  cover  is  buttoned 
to  the  under  edge  of  the  table  top,  as  the  removable  sides  of  a 
carrijige  are  fastened  on. 

Fixed  or  portable  rests  for  the  feet  are  an  advantage,  because 
with  the  fe(»t  slightly  el(»vat(»d  above*  the  surface  of  the  table  and 
at  a  short  distance  IxTond  th(»  table's  edge  the  alMlominal  muscles 
are  more  thoroughly  n^laxed  and  the  i)atient  is  more  comfortable 


PREPAR.\TION  OF  TABLE  AND   INSTRUMENTS  27 

than  she  is  with  heels  clo^  to  the  buttocks,  and  slipping  off  the 
table. 

In  private  houses  the  kitchen  table  is  always  availablo  or,  if  it 
is  best  in  occasional  instances  to  examine  the  patient,  in  bed,  an 
ironing  board  or  bread  board  may  be  placed  on  the  mattress  under 
the  patient's  hip8,  which  shoidd  be  at  the  etlge  of  the  lM?dj  the  feet 
resting  in  two  chairs.  A  foklod  blanket,  or  two  thicknesses  of  a 
comforter,  should  be  laid  on  the  table  or  board  to  take  away  tlie 
hardness.   In  this  way  the  jmtient  is  reasonably  com  f  nil  able  during 


FiQ,  h— The  Exuniimng  Table. 

tbe  nhort  time  occupieil  by  the  examination  and  the  physician  can 
do  his  work  to  the  best  advantage. 
There  are  few  points  of  superiority  and  many  rlisadvantages 
the  compticatf»<l  and  costly  tablc^s  sold  in  the  instrument  shops, 
patient  is  not  at  ease  on  an  unstable  surface  antl  she  does  not 
Dke  to  feel  that  by  the  pressure  of  levers  she  may  be  tilted  into  all 
8Drtj9  of  positions;  she  is  not  in  a  state  of  mind  to  appreciate  tlie 
beauty  of  the  ingenious  mechanLsm  concealeil  in  the  table,  aud 
would  rather  lie  on  a  solid,  warm  wooden  table  than  on  a  hard, 
one,  made  of  glass  and  iron. 


^ 


28  PHYSICAL  EXAMINATION 

The  ordinary  vaginal  examination  need  not  Ix)  a  strictly  aseptic 
operation,  and  it  calls  for  clean,  not  aseptic  furniture. 

Suppose  we  have  the  table  placed  with  its  end  toward  a  good 
light.  We  cover  it  with  a  folded  comforter  and  a  sheet,  unless  it 
is  already  provided  with  a  permanent  cushion.  When  the  patient 
lies  on  her  back  with  hips  and  heels  at  the  edge,  the  only  portion 
of  the  table  which  will  come  in  contact  with  the  region  about  the 
vulva  and  anus  is  a  narrow  part  of  the  middle  of  the  end,  some 
two  inches  wide  and  six  inches  long.  Therefore  for  every  patient 
a  fresh  towel  is  opened  just  as  it  comes  from  the  laundry  and  a 
newspaper  is  folded  into  it  so  that  the  original  folds  of  the  towel 
are  reproduced.  This  towel,  about  six  inches  wide  and  a  foot 
long,  is  now  placed  in  the  middle  of  the  examining  end  of  the 
table  and  one  end  tucked  under  the  comforter  or  cushion.  The 
surface  to  sit  upon  is  thus  some  six  by  nine  inches,  according  to 
the  size  of  the  towel.  In  this  way  each  patient  sits  on  an  abso- 
lutely frash  towel,  and  the  table  is  protected  from  the  vaginal 
discharges  or  solutions  used  by  the  physician,  by  the  newspaper 
which  has  been  folded  into  the  towel. 

It  is  seldom  necessary  to  soil  the  sheet  or  cushion.  If  by  any 
chance  it  is  soiled,  as  in  case  of  hemorrhage,  the  sheet  or  towel 
is  removed  and  the  enameled  canvas  surface  of  the  cushion  is 
washed  and  a  fresh  sheet  or  towel  put  on.  A  pillow  for  the  pa- 
tient's head  is  placed  at  the  head  end  of  the  table. 

Care  of  the  Instruments 

X'^ery  few  instruments  are  necessary  for  the  routine  gynecological 
examination.  A  uterine  dressing  forceps,  a  sound,  and  a  small- 
sized  bivalve  speculum  are  frequently  all  that  will  be  requu-ed. 

It  is  best  to  keep  all  instruments  out  of  the  patient's  sight, 
because  she  does  not  admire  them  nor  look  at  them  from  the  same 
point  of  view  as  the  doctor,  and  it  is  not  at  all  reassuring  to  feel  that 
all  the  bright  instruments  of  seeming  torture  may  be  used  on  her. 

My  full  kit  contains  the  following  instruments: 

Flexible  uterine  sound; 

Uterine  probe; 

Bozeman  uterine  dressing  forceps; 

Uterine  tenaculum,  single; 


rUEPARATIOX  OF  TABLE  AND   IN8T1U  MENTS 


29 


Uti*rine  trnaculuin,  iloublc,  or  vubclluin; 

Uterine  gicis^ors; 

SilvcT  ukTiiif*  [iroJx' : 

Small-size  Brewer  bivalve  speculum ; 

Graves  bivalve  speculum; 

Smallest  size  Sims  8|>eeukmi,  al^o  No.  4  size: 

Eklebohls  s{>eeulum  (ineludeti  in  the  kit  for  eases  in  which 
euretting  or  removal  of  a  piece  of  tissue  is  nece^^stu-y  for  diagnosis ) ; 

Hunter  vaginal  depressor; 

Emmet  curette  forceps; 

Bozenmn-Frits(^h  uterine  douche; 

Two  uterine  applicators; 

Uterine  sharp  curette  with  flexible  shaft; 

Set  of  Hanks  metal  uterine  dilators; 

Warthen  uterine  dilator; 

Silver  female  catheter; 

Kelly  meatus  calibrator: 

Set  of  KelJy  double-endetl  steel  uretliral  sounds; 

Kelly  cystoseopes,  Nos.  S,  10,  12; 

Alligator  bladiler  forceps; 

Two  Kelly  ureteral  catheters; 

Kelly  proetojicoixNs,  two  sizes; 

Kelly  ureteral  searcher,  and  rubber  bulb  and  tube  for  suction; 

HeaiJ  mirror; 

Stethoscope; 

Pelii  meter. 

Added  to  these  are: 

Two  sterile  two-ounce  l»ottles; 

Compressed  tablets  of  cocaine  hydrochlorate; 

Sterile  absorbent  cotton ; 

Sterile  gauze; 

A  bottle  of  creolin: 

Cover  gla.s?«es. 

A  collajieible  tube  of  a  sterile,  soluble  lubricant  sold  under  tlie 
names  of  Lubrichondrin,  Glycerine  Emollient,  Muco^  or  K-Y 
Jelly. 


It  is  my  practice  to  have  one  set  of  instruments  in  a  drawer 
within  easy  reach  of  niy  right  hand  as  I  sit  in  front  of  my  examin- 


30  PHYSICAL  EXAMINATION 

ing  table;  another  set  is  in  a  bag  ready  to  be  carried  to  consulta- 
tions at  the  patients'  homes. 

After  use  the  instruments  are  scrubbed  with  soap,  hot  water,  and 
a  nail  brush,  rinsed  with  boiling  water,  dried  at  once,  and  put  away 
clean.  In  cancer  cases  and  those  in  which  infectious  matter  is 
pretty  surely  present  the  instruments  are  boiled  in  soda  as  well  as 
scrubbed  with  soap  and  water  before  bemg  put  away.  Before  use, 
the  instruments  which  it  is  thought  will  be  used,  are  placed  in  a 
shallow  enameled  iron  tray  and  boiled  for  five  minutes  in  a  one- 
per-cent  solution  of  washing  soda  in  water;  the  soda  solution  is  then 
poured  off  and  hot  water  substituted.  No  instruments  are  ever  let 
lie  for  any  length  of  time  after  use  without  being  washed.  Until 
cleansed  they  are  always  kept  immersed  in  water  so  that  discharges 
and  blood  can  not  dry  on. 


III.   THE  EXAMINATION 

1.  Preparation  of  the  physician  and  placing  the  patient  on  the 
table. 

2.  Inspection  of  the  external  genitals. 

3.  Palpation:  (a)  The  vaginal  touch.     Dorsal  position. 

(6)  The  combined  bimanual  vaginal  and  abdom- 
inal touch,  including  points  in  the  anatomy 
and  the  findings  on  palpation. 

(c)  The  rectal  touch. 

(d)  The  bimanual  recto-abdominal  touch. 

(e)  Positions  of  the  patient  used  in  gynecological 

examinations  other  than  the  dorsal;  the 
Sims  position;  the  knee-chest  position;  the 
lithotomy  position;  the  raised  pelvis  posi- 
tion; the  standing  position. 

4.  Odor  as  a  diagnostic  sign. 

5.  The  collection  of  the  discharges  and  tissues  for  bacteriological 
examination. 

6.  Inspection  of  the  abdomen. 

7.  Palpation  of  th(»  alxlomen. 

8.  Percussion,  auscultation,  and  mensuration  of  the  abdomen. 

9.  Instruments  and  their  use  in  diagnosis. 


THE  KXAMIXATION 


31 


L  Preparahom  of  the  Physician  and  Pu^cino  the  Patient 

ON  THE  Table 


The  physician  preparers  himself  by  washing  his  hainJs 
carefully  and  if  they  are  cold  by  warmmg  thcni,  and  by 
pulling  up- the  sleeves  of  his  coat  and  hLs  cuJTs  so  that  they 
will  not  come  in  contact  with  tiie  patient.  As  to  rul>f>t*r  cots 
and  rubber  gloves,  they  interfere  with  the  tactile  sense,  how- 
ever used,  and  should  l^e  employed  only  in  exceptional  in- 
stances, as  in  cases  of  suspected  gonorrhea  and  of  ft^tid  dis- 
charge,   also    in    rectal    examinations.      They   serve   to   protect 


huv 


i    ..iininirig  IIlhiiI,  iShowing  rmU-ftive  Sleeve, 


fsoming  patienta  and  also  the  physician  from  contamination,  as 
mocuUtion  with  syjihilis,  and  favor  the  cause  of  asepsis.  The 
physician  who  is  personally  neat  anil  washes  his  hands  care- 
fully Ix^fore  as  well  as  after  a  vaguial  examination ^  need  have 
no  fear  of  carrying  bacteria  from  [latic^nt  to  patient.  The 
exanuiiation  can  not  be  so  well  made  with  cots  or  gloves  as  without 
them^  therefore  do  not  ust*  them  unless  necessar>^ 

As  to  protecting  the  slei*ves,  it  is  a  grnid  jjlan  to  worn'  sleeves 
niftde  of  "Stork  sheeting"  or  thin  rubber,  with  elastics  at 
the  \%Tista  and  elbows,  pullnl  tm  tner  the  coat  skives.  These 
rubber  sleeve^t  can  be  freijuently  cleanscMl  and  they  prevent 
eairying  inf(X'tion  from  anv  patient  to  another.  They  ot>viate 
tbc  ncccsrfty  of  removing  the  coat,  a  procedure  which  is  undesir- 


32 


PHYSICAL  EX.\M1NATI0N 


able  bpcause  it  seems  to  intlicate  to  the  patient  formidable  mi- 
(iriiakings. 

Of  the  iniportanre  of  washing  the*  haiuls  iK'fnre  th(^  examination 
too  much  can  not  he  said.  Oni*  never  knows  what  Imcteria  he 
may  have  on  his  hantls  and  under  his  finger  nails.  Every  one 
necessarily  washes  hh  Irnnds  after  the  examination;  how  much 
more  essential,  from  the  standpoint  of  the  patient's  safety,  h  the 
preliminary  wash.  He  who  woulii  [jraetice  gynecology  must  ha\*e 
the  handwashing  habit. 

It  is  my  custom  to  prepare  a  Imsin  full  of  w^arm  creolin  solution, 


one  i>er  cent,. and  place  it  on  the  instrument  table  within  reach  of 
my  right  hand.  As  lx*fore  stated,  the  examination  is  not  and  ncn^d 
not  Ik*  a  strictly  ase|)tic  operation;  tliercf  ore  some  antiseptic,  w'hieh 
does  not  coagulate  the  allnnjjen  of  thi!  discharges,  has  an  odor  of 
its  own,  does  not  corrode  instriunrnts,  nor  irritate  the  tissues,  is 
indicated.  Any  talJe  will  serve  on  which  to  lay  the  pan  of  instru- 
numts,  Imsin,  and  sttTik*  cotton,  A  low  table  is  preferable  to  a 
high  one.  Its  surface  should  te  covert^d  with  a  fresh  toweh 
The  usual  position  employed  in  gynecological  examinations  is 


INSPECTION    OF    EXTERNAL   GENITALS 


33 


_       hini 


the  (loi^tal  position.  The  Sims  position,  the  knet^ehest  position, 
the  elevated  pi^lvis  po^^ition,  the  hthotomy  position^  aud  the  stand- 
ing position  wiU  \je  <Jescribed  later* 

The  Dorsal  Position, — Evenlhing  lieing  in  readini'ss,  the  patient 
ste(j8  into  a  hani-bottomed  ehair  placed  at  the  foot  of  the  tal>lc 
and  raiises  all  her  skirts  Ijehind,  the  physician  meanwhile  f^tanding 
in  fmnt  of  her  anti  holding  up  a  yheet,  so  that  she  is  screened  from 
hini  as  ^he  sits  on  the  little  folded  towel  on  the  edge  of  the  table. 
She  lies  do^ii  antl  puts  her  feet  in  the  supports.  To  prevent 
hiing  the  bwck  it  is  well  to  a^sk  the  patient  to  draw  up  her  knees 
B  she  lies  dowTi,  othen^xsp  fier  back  will  reach  the  cushion  while 
her  feet  are  still  in  the  ehair,  putting  her  into  a  sort  of  WalchtT 
position,  one  of  great  diseonifort. 

The  sheet  is  now  thrown  over  the  nTiinilx^nt  w^mian  so  tliat 
she  is  entirely  eovvreiL  Holding  the  lower  nige  of  the  sheet  in 
the  h'ft  hand  the  ph>Vieian  raises  the  patient's  skirts  in  front  with 
his  right  hand  under  the  sheet.  Then  by  carrying  the  middle  point 
of  the  sheet  U))ward  to  tlie  pu!ne  rt*gion  both  thighs  are  ilrape<l  and 
only  the  vulva  and  anal  regions  are  e\p{>se<L  A  woman  does  not 
object  to  an  exposure  of  the  genitals  that  is  nianifestly  necessary 
!*o  long  as  the  surrounding  parts  and  the  body  are  covered  up. 
This  method  of  coverifig  with  theshtvt  is  aj)plieable  to  every  sort 

Eof  a  ea*H%  and  shoukl  be  enijiloyed  always  unless  the  patient  is 
kie5tbetize<l 
If  the  examination  is  at  the  patientV  lionn'  tlie  tablf*  is  (prepared 
in  a  gooil  light  in  her  nx»m  and  she  eithrr  walks  to  the  examining 
t^bie,  Of,  if  unabk'  to  walk,  is  carried  from  the  bed. 


2.    LvSPKiTION    OF    THE    EXTKKNAL   <5kMTAL8 


There  is  no  valid  objection  to  an  inspection  of  the  vulvar  region; 
in  fact,  a  pri>iHT  <liagnosis  can  not  Ix'  nmd<*  without  it.  The  iihysi- 
cian  sweats  hinus<»lf  m  the  chair  uschI  by  the  patient  to  get  upon  the 
table,  atid  spreads  a  fresh  towel  over  hb  knees.  By  placing  the 
fingers  of  eaeh  hand  on  the  labia  majora  the  labia  are  drawn  gently 
mut^il  he  notes  the  condition  of  the  hymtm,  whether  with  one 
•wOHwoi>enings,  unbmken  or  ljrokf*n;  the  amount  and  charaeter 
of  the  vaginal  tiisoliarge;  the  ap|>earance  of  redness  alx)ut  the 
orifie(*s$  of  Bartholin's  glands  or  Skene's  glanrls. 


34  PHYSICAL  EXAMINATION 

If  redness  appears  about  the  orifices  of  Skene^s  glands,  the  well- 
anointed  finger  should  be  introduced  for  an  inch  into  the  vagina, 
pressing  backward  toward  the  sacrum  with  the  dorsum  of  the 
finger  as  it  is  slipped  into  the  vagina,  and  gentle  pressure  made 
with  the  tip  of  the  finger  along  the  course  of  the  urethra  from 
above  downward  to  express  pus  from  the  glands. 

He  notes  further  the  condition  of  the  meatus  urinarius,  whether 
closed  or  open ;  the  prepuce,  whether  adherent  to  the  glans  clitoridis 
or  not,  and  injuries  of  the  perineum.  The  surface  of  the  perineum 
between  the  fourchette  and  the  anus  shoukl  present  a  convexity; 
if  it  is  flat  or  concave  it  means  an  injury  to  the  pelvic  floor  or 
perineum. 

Palpation  is  to  Ix^  combined  with  inspection  in  determining  the 
nature  and  extent  of  injuries  in  this  region.  (See  Chapter  XX, 
page  372.)  One  must  be  on  the  lookout  for  skin  affections.  Pedi- 
culi  are  occasionally  found  among  the  poorer  classes;  and  all  sorts 
of  anomalies  of  the  external  genitalia  are  to  be  looked  for.  In- 
spection of  the  vagina  will  be  taken  up  in  the  chapter  on  the  use 
of  instruments. 

3.  Palpation 

Palpation  includes  the  vaginal  touch,  the  combined  bimanual 
vaginal  and  alxlominal  touch,  the  rectal  touch,  and  the  combined 
bimanual  recto-abdominal  touch.  The  examination  of  the  abdo- 
men will  be  considered  in  another  chapter. 

(a)  The  Vaginal  Touch. — The  physician  has  washed  his  hands 
with  care,  his  nails  are  always  trimmed  short  and  are  clean,  and 
his  hands  are  warm.  He  stands  facing  the  patient,  who  is  in  the 
dorsal  position  on  the  examining  table.  Now  comes  the  question 
which  hand  to  use  for  the  vagina.  I  prefer  the  left  hand  for  the 
reasons  that  the  left  hand  is  less  frequently  usc^d  for  ordinary  pur- 
pos(\s  than  the  right;  therefore,  the  skin  covering  the  terminal 
phalanx  of  the  left  fon^finger  is  softer  and  capable  of  higher  training 
of  the  tactile  sense;  less  strength  is  required  of  the  examining 
hand  at  the  vagina  than  of  the  hand  on  the  abdomen,  which  is 
engaged  in  gross  manipulations,  the  right  hand  is  usually  the 
stronger  except  in  the  case  of  left-handed  persons;  the  left  hand 
is  generally  a  trifle  more  flexible  than  the  right  hand,  an  important 


I 


PALPATION 


35 


I 


uu- 
■     du 


I 


consideration  with  reference  to  stowing  away  the  unused  fmgens, 
and  finaJJy,  usbig  the  left  finger  for  the  examination  leaves  free  the 
highly  trained  right  Imnd  for  the  delieate  manipulation  of  instru- 
ments. 

Whichever  finger  is  chosen,  that  ont*  should  be  used  in  alt  but 
unuKual  cases,  Ix^eause  it  is  desirable  to  educate  one  finger  to  fwl 
correctly.  It  is  the  exceptional  physician  who  can  become  ambi- 
dextrous* 

Having  decided  on  the  left  forefinger,  it  should  be  lubricated 
becauise  the  external  genitals  are  ilry,  and  pushing  in  the  external 
parts  cau.ses  the  patient  ilisconifort :  it  is  the  t?kin  which  is  in  need 
of  lubrication  rather  than  the  vagimi,  which  is  supplieil  normally 
with  a  lubricating  medium,  then:*fore  anoint  the  external  labia  and 
theses  in  turn  will  luljricate  the  finger.  The  iMAst  hiliricant  is  some- 
thing of  the  naturt^  of  lubrichondrin,  sokl  under  the  name  of  *'  myco- 
lubricans'*  or  **K-Y/*  prepared  from  cartilage  treated  with  heat, 
a  mildly  antisejjtic  jelly  containing  eucalyptol  or  gaultheria,  or 
^me  other  su Instance  to  give  it  a  pleasant  odor.  It  is  soluble  in 
wattT*  It  is  kejit  in  a  str  rile,  coIla[>sible  tulx*  and  is  free  from  all 
danger  of  contamination.  The  oils  and  vaseline  are  peculiarly  ill 
«uited  for  lubrication  Ix^ause  they  cling  to  the  finger  and  instru- 
ments and  are  well  adapted  to  receive,  retain,  and  distributt*  juitlio- 
gdiie  organisms.  Soaps  are  irritating  to  many  patients,  particu- 
larly in  inflammatory^  conditions  of  the  external  genitals.  The 
physician  s<jufH'zes  fmm  the  tuU*  an  ample  (juantity  of  lubri- 
diondrin  on  to  thciiorsal  aspect  of  his  forefinger,  anointing  only  the 
temiinal  and  second  jihalanges.     By  bringing  the  hand  downward 

til  the  little  and  ring  fingers  touch  tlie  table  just  under  the  cleft 
trf the  buttocks,  the  tijj  of  the  anointt^l  forefinger  seeks  the  perineum, 
Wlien  it  is  reacheil  thc^  back  of  the  IxTit  forefinger  is  drawn  upward 
over  the  fourchette,  thus  Inbricating  the  laliia  and  the  vestibule, 
the  knuckle  falling  into  the  dcjiression  at  the  introitus  vaginte, 
A  secon*!  sweep  with  the  finger,  it  is  straightened,  ami  the  ti|>  settles 
into  the  vagina.  It  is  to  be  notetl  that  the  luliricant  has  been  put 
rmly  wh«»re  it  is  needetl  and  that  there  is  none  on  the  unused  hand 

id  on  the  patient's  linen. 
n  introflucing  the  finger  into  the  vagina  one  bears  in  mind  the 
condition  of  the  hymen  as  notetl  at  the  previous  inspection.     If 
the  hynien  is  tight  great  gentleness  should  be  used  and  sufficient 


36  PHYSICAL  EXAMINATION 

time  allowed  for  dilatation.  Room  in  the  vagina  is  always  to  be 
gained  by  pressing  backward  toward  the  sacrum,  as  the  perineum 
and  pelvic  floor  are  dilatable  in  this  direction  only.  The  structures 
which  hug  the  under  surface  of  the  pubic  arch,  the  clitoris,  vestibule, 
anterior  vaginal  wall,  and  urethra  should  be  avoided  as  far  as 
possible,  as  in  that  region  sensation  is  most  acute. 

The  examining  finger  may  be  likened  to  a  small  speculum  as  it 
carries  down  the  perineum  and  opens  the  vagina.  In  many  cases 
it  is  possible  to  use  the  finger  in  the  place  of  a  speculum. 

As  soon  as  the  middle  knuckle  of  the  examining  finger  has  passed 
the  hymen  the  hand  is  turned  so  that  the  thumb  is  upward.  The 
three  unused  fingers  are  carried  be»hind  the  anus  in  the  cleft  of  the 
nat<^s  and  the  thumb  is  moved  to  the  left  or  right  of  the  median 
line  out  of  the  way  of  the  clitoris.  The  perineum  and  pelvic  floor 
can  be  pushed  in  to  a  variable  extent  by  the  web  Ixitween  the 
index  and  middle  fingers  and  thus  the  examining  finger  reaches 
farther.  It  is  seldom  necessary  to  employ  two  fingers  for  the 
vaginal  examination,  although  there  are  cases  where  more  may  be 
learned  with  two  than  with  one.  The  palmar  surface  of  the  last 
phalanx  of  the  forefing(»r  is  the  chief  seat  of  the  trained  tactile 
sense.  As  a  nil(»,  parficularly  in  virgins,  two  fingei"s  cause  the 
pati(*nt  a  great  deal  of  discomfort  and  therefore  accentuate  the 
disagreeable  f(»atures  of  the  exammal^on,  t(*nduig  to  distress  of 
mind  and  body  and  consequently  preventing  the  relaxation  so 
essential  for  a  succ(\ssful  investigation  of  the  contents  of  the  pelvis. 
The  scope  of  the  vaginal  touch  (h^pends,  in  a  measure,  on  the  ana- 
tomical pe(*uliarities  of  the  examinee's  hand.  A  physician  ha\ang 
thick,  chunky  hands  with  short  fat  fingcTS  can  not  hope  to  be  as 
good  a  gynecological  diagnostician  as  oiu)  havmg  a  slim  hand  with 
long,  tapering  fing(TS.  In  women  of  spare  build  who  have  borne 
children,  practtically  the  entire  inner  surface  of  the  pelvic  caxity 
may  be  palpat(^d  by  a  long  finger  or  fingers  introduced  uito  the 
vagina.  It  is  not  unusual  to  touch  the  promontory  of  the  sacrum 
and  the  sacro-iliac  synchondroses,  })esi(les  all  parts  of  the  fXilvic 
floor,  not  to  mention  the  structures  occupying  the  pelvis.     (See 

Fig.  -1.)        _ 

The  examining  finger  as  it  enters  the  vagina  notes  the  following 
points: — The  state  of  th(^  hymen,  whether  with  large  opening  or 
small,  whether  rigid  or  easily  dilatable;  the  vaginal  walls,  whether 


PALPATION 


37 


with  rugiv  or  s^iiiootli,  wht'thtT  of  noruial  teiiipcratun*,  or  hot,  as 
in  the  case  of  inflanimatory  aflVt'tioos  of  the  pelvic  organs,  or  in 
fevers;  whether  the  walls  of  the  vagina  are  in  apposition,  or  lax 
or  separatetl;  the  afnount  of  swrrtion,  a  dry  vagina  gi^^ng  an  en- 
liR*ly  different  s4.*nsation  from  a  moist  one;  the  condition  of  the 
pelvic  floor  and  perineum;  in  the  case  of  a  parous  woman  sttarch 
for  a  groove  in  either  suleus  or  the  middle  lino,  rcmemlx:*ring  the 
nornml  conformation  of  the  |XTin(nmi,  that  is  to  say,  a  convex 
fiturface  in  the  vagina  as  well  as  oti  the  skin  outside;  sometimes  it 
is  wvll  to  introduce  the  well-anointed  forefinger  of  the  right  hand 
in   the   anus   and    palfjate    the   tissue    lying    lx*tween    the  tw^o 


■     he  I 


Flo.  4. — ^llalf  a   I'VinaJc  Pelvis,  with   Hand   in   Position   a«  /or   Vaginal 

Fjxamination* 


:ers  in  onler  to  get  a  cujrreet  i<lea  as  to  injuries  which  may 
be  proftciit.  The  vaginal  touch  infomis  us  as  to  the  contents  of 
tbc  rectum,  tvhether  emjtty  or  containing  hard  fiscal  masses,  s<»nii- 
8olifi  feces,  or  dilatcnl  by  fluid  or  gas;  also  wliether  or  no  the  blad- 
der y  fiist^^ndtnl. 

In  onler  to  prmHice  this  sort  of  palpation  succ(»ssfuUy  re- 
quires a  long  exjjerience  and  a  thorougli  familiarity  with  the 
normal  conditions,  also  the  variations  of  the  normal  in  different 
iiidividtmls. 

Abnormalities  of  the  vagina  are  to  be  detected  by  touch ;  such 
am  cystis,  partial  scptujii,  narrowmg  of  the  lumen  by  cicatrices^ 


la,.  .J.— Diiignuiimatic  Drawmg,  Illustnaing  thc^  Hiiiuumul  Touch, 

flieating  tho  f^itiiation  of  ulcerated  an^as  in  the  Ijladtler  iiiufom. 
Tlie  ureterH  wlic^ri  thiekenrd  arc*  easily  iml|)ablr  I'uruiitig  from  tlie 
bladder  bas<^  toward  the  ^arro-iliae  synchondroses.  Tho  iii>p(T 
eourso  of  the  iielvie  j>oHion  rjf  the  ureters  can  be  lx\^t  detected  by 
reetal  examination. 

(h)  The  Combined   Bimanual   Vaginal  and   Abdominal   Touch.^ — 
^\Tien   the  tip   of    the   examining    finger  reaches    Ihe    posterior 


PALPATION 


39 


I 


fornix  of  \hv  vaf^ina  thr  [jhy.sii-iafi's  right  hand  is  laid  gt-ntly 
on  the  lower  alxlonien,  palm  ilown  willi  tlm  hri'l  of  tlip  liarul 
]ugt  aljove  the  symphysijis  pubis.  Very  gentle  and  slowly  applied 
pn^*^ure  is  rriaile  with  this  abdominal  hand,  all  siuiden  movement 
bcnng  avoi(ksi  as  calculated  to  exeite  pain  and  consequently 
reristancc  of  the  alxlominal  muscle??.  The  balls  and  not  the  tips 
of  the  fingers  are  ust^L  The  pelvic  organs  are  <-arrie(l  down  l>y 
the  pressure  alx)vc  until  they  are  witliin  reach  of  the  finger  in 
lh€*  vagina,  and  conversely  they  are  raised  by  the  fingcn^  Ix^low 
until  within  touch  from  ahivc.  In  the  case  of  the  bimanual 
Vftgin<>a^Klominal  touch  we  hf>ld  Ijetween  our  hands  (the  finger  in 
the  vagina  and  the  hand  on  the  alj<lom(*n)  the  contents  of  a  Imx, 
the  cavity  of  the  pelvis. 

It  is  sometimes  a  help  in  making  th**  IjiTnanual  examination  for 
the  physician  to  rest  tlie  cibtiw  of  the  hand  making  tlie  vaginal 
iciurh  on  the  knei»  of  the  corn^sponding  leg,  his  f(K>t  (x4ng  placed 
on  the  chair  which  is  close  to  the  table. 

Factors  outside  of  the  condition  of  the  lx)W"els  and  rectum 
limiting  what  can  hf  felt  l>y  ttie  bimanual  toucli  are,  tlie  amount  of 
ailipoe«c  tissue  pn^st^nt,  and  the  rigidity  or  laxity  of  the  muscles 
of  the  alj<lominaI  walls.  A  rigid  perineum  has  been  n^ferrerl  to 
already  as  lessening  the  amouTit  of  invagination  of  tht^  pelvic  floor 
that  may  Ix*  maile  l)y  the  web  Ix^tween  the  fingers  of  tlie  lumd  at 
the  vulva. 

In  fat  women  lH)th  the  viiginal  and  bimanual  touch  are  in- 
ennl  with.  Other  things  l>eing  e<jual,  it  is  impossible  to 
make  as  accurate*  a  diagnosis  in  a  fat  woman  as  in  a  thin  woman. 
Tht*  fat  in  the  |X'rin**al  rc*ginn  reduces  tht*  s(*ope  of  the  vaginal 
touch.  A  greater  hindrance  is  the  fat  in  the  alxlominal  walls; 
nith  two  or  three  inches  of  fat  in  the  pannicuhis  adiposus  the 
die  sense  is  much  Wuntcd,  It  is  like  feeling  ihrougli  six  or 
light  thicknesses  of  l)lankets.  Naturally ,  th<'n,  w(*  do  not  hope 
to  make  as  goo*t  a  diagnosis  as  when  the  abdominal  waUs  con- 
little  fat. 

A  rigid  al>domen  is  a  Imr  to  iliagiiosis  by  touch.  One  can  feel 
it  tie  through  a  stiff  sheet  of  past(4)oarfL  If  there  is  |>resent 
itis  or  gn^at  sensitiveness  of  the  alwlomen  from  any  cause 
we  expect  to  find  rigidity.  Many  patients  become  rigifl  through 
iety  and  fear  of  painful  mani|*ulations  by  the  physician,  others 


i 


40  PHYSICAL  EXAMINATION 

reflexly  because  of  the  discomfort  caused  by  the  laying  on  of  the 
hands.  Therefore,  not  only  is  the  utmost  gentleness  imperative, 
but  also  it  is  a  matter  of  supreme  importance  not  to  arouse  the 
patient's  fears  by  brusk  behavior,  or  by  the  uncalled-for  display 
of  instruments. 

As  to  gentleness,  the  flat  hand  on  the  lower  abdomen  makes 
light  pressure  and  the  physician  inquires  whether  it  causes 
pain.  Distracting  the  patient's  attention  by  a  question  or  two 
often  prevents  rigidity.  Next,  the  hand  is  arched  by  flexing 
slightly  all  the  fingers  so  that  the  balls  of  the  fingers  press  in 
deeply.  It  is  very  essential  not  to  make  the  tips  of  the  fingers 
press,  the  same  rule  holding  here  as  in  massage.  Make  pressure 
with  the  palmar  surface  of  the  last  phalanges,  for  the  tips  of 
the  fingers  and  the  finger  nails  cause  pain,  and,  also,  less  can  be 
felt  with  the  tips. 

Ask  the  patient  to  take  a  long  breath;  as  she  does  so,  gently  hold 
the  abdominal  wall  in.  Repeat  the  process  and  the  examiner's 
hands  are  brought  nearer  and  nearer  together  with  each  expiration. 
Judgment  is  necessary  in  performing  this  maneuver  because  too 
rapid  or  too  forcible  pressure  will  cause  the  abdominal  muscles  to 
contract,  thus  defeating  the  objects  of  the  examination.  Assist- 
ance is  gained  in  some  rare  cases  by  drawing  down  the  cervix 
with  a  tenaculum  lield  by  an  assistant.  In  this  way  the  back  of 
the  uterus  and  the  broad  ligaments  are  reached  and  also  tumors 
and  other  attachm(^nts  are  made  out. 

The  bimanual  or  conjoined  examination  is  the  keystone  of  the 
gynecological  diagnostic  arch.  Nothing  takes  the  place  of  the 
trained  touch,  and  it  is  doubtful  whether,  in  the  march  of  progress, 
any  form  of  investigation  will  supi)lant  it. 

Specula  for  the  vagina,  the  bladder,  and  the  rectum,  bacteriology, 
and  the  microscope  with  its  findings  as  to  the  nature  of  the  blood 
and  tissues,  and  the  x-rays,  detecting  a  stone  in  the  bladder, 
ureter,  or  kidney,  all  have  their  uses.  The  bimanual  touch  is  the 
most  important. 

The  finger  in  the  vagina  notes,  first,  the  situation,  size,  conforma- 
tion, consistency,  and  sensitiveness  of  the  cervix;  lacerations, 
their  location  and  extent ;  whether  or  no  the  tissues  of  the  cervix 
are  of  normal  consistency,  or  soft  as  in  septic  conditions  or  after 
labor,  or  indurated  as  in  chronic  metritis.    The  friable,  bleeding 


PALPATION 


41 


» 


cervist  iSi^Sicer  is  rarely  mistaken  for  an 3'  other  eondition,  except 
pogsibly  a  sloughing,  iKHiurieulated  hhroid. 

Cysts  of  the  Nabothian  follicles  can  be  diagnostieated  as 
shot-like  bodies;  a  stringy,  tenacious  plug  of  mueus  in  the  os 
can  be  differentiated  from  a  thin  di.^eharge:  in  rare  cases  the 
cervix  may  be  out  of  reach,  being  forced  upward  into  the  abdomen 
by  a  tmnor  in  the  pelvis  so  that  it  may  lie  on  a  level  with  the 
upper  l)order  of  the  sjiiiphysis  pubis;  the  different  situations  of 
Uie  cer\ix  in  the  various  malpositions  and  malformations  of  the 
TUB  will  be  considered  in  the  chapter  devoted  to  these  diseases, 

;e  long  conical  cer\ux  found  espt^eially  in  jiathologieal  ante- 
flexion^ 80  called,  is  readily  distinguished  from  its  opposites,  the 
apparently  short  cervix — one  in  which  the  vagina  has  teen 
stripped  by  chiltUx^ariog  from  its  attachments  to  the  portio,  or 
from  the  really  short  senile  cervix. 

The  pinhole  os  is  differentiat*^!  by  touch  from  the  os  tinea*. 
By  the  vagmal  touch  we  detect  a  polypus  projfH-ting  from  the  os 
uteri.  In  the  case  of  large  |>olypi  we  detect  the  location  and  size 
of  the  i>e<:licle  by  sweeiJing  the  finger  about  the  tumor  anil  noting 
where  and  how  it  is  attaeheil.  Sensitiveness  of  the  cervix  to  light 
pressure  indicating  endocervicitis  is  to  be  sought  for.  A  prolapsed 
ovary  or  tube  may  tw  felt  on  one  side  of  the  cervix  and  an  excursion 
to  one  of  the  sacro-iliac  joints  may,  in  rare  easels,  detect  tenderness 
aad  induration  there. 

Palpating  the  normal  ovary  by  the  bimanual  touch  is  a  difficult 
ttc*r  unless  all  the  conditions  are  favorable.  These  niv,  a  |>atient 
h  thin  and  relaxed  alxlominal  walls  and  an  injurf^l  perineum, 
rruler  such  circumstances  the  ovary  may  be  rolled  between  the 
fingers  of  the  examiner's  hands.  Whenever  the  ovary  is  enlarged 
from  any  cause  it^  palpation  is  rendered  easier  In  the  case  of 
rigid  abdominal  walls,  large  dejjosits  of  fat  in  these  structures,  a 
tight  hymen  and  unyielding  perineum,  tlie  palpation  of  the  ovary 
beromes  difficult.  Often  only  the  uniler  surface  can  be  felt,  and 
'Wnetimes  only  by  a  rectal  examination.  Note  the  sensitiveness 
to  pressure  of  the  normal  ovary  and  in  the  case  of  a  diseased  ovary 
inquire  of  the  patient  if  the  pain  caused  by  pressure  is  the  same  as 
that  suffered  at  other  times. 

The  Fallopian  tube  can  not  be  felt  by  bimanual  examination 

less  it  is  thickened  or  enlarged  by  disease.    In  this  event  it 


42  PHYSICAL  EXAMINATION 

may  be  mappal  out  with  varying  degrees  of  exactness  according 
to  the  condition  of  abdominal  wall  and  perineum. 

An  abscess  in  the  pelvis,  whether  originating  in  the  tube,  the 
ovary,  the  vermiform  appendix,  the  sacro-iliac  joint,  or  coming 
from  above  in  the  psoas  muscle,  may  be  mapped  out  by  the  bi- 
manual touch  and  a  point  of  fluctuation  found  if  it  exists. 


I 


HI.  The  examination  {rontmtu*d) —- ^,  Palpation  (row/ miW) :  Anatomy 
at  the  pelvic  contents,  p.  4*1  Barriers  to  infection,  p.  All.  Mobility  of  the 
litem**  p.  44.  The  uterine  ligaments*  p.  44.  Meclianics  of  the  f>eivic  and 
ftbdouiinaJ  contents*  p.  44.  The  f>elvic  circulation,  p.  4(1.  The  normal 
position  of  the  uterus,  p.  49.  Stroctyres  to  be  distio|Tt(ished  by  palpation, 
p.  49,  Inferences  to  be  drawn  from  palpation,  p.  *jO.  (c)  The  rectal  touch, 
p,  50.  {d)  The  recto-ab<Jominal  touch,  p*  5>i.  (c)  Gynecological  [wisitions 
otlier  than  the  dorsal  position,  p,  .5.S:  The  Sims  fMJsilion,  p.  54:  The  knee- 
ehest  pi>sition«  p.  ,56;  The  lithotomy  position,  p.  57:  The  raised  j^wlvis 
fiosition,  p.  58;  The  standing  position^  p,  59. 

4.  Odor  as  a  dijignoslic  sign,  p,  tK). 

5.  The  ci>llection  of  the  dischnrges  an«l  tissues  for  microscopic  examina- 
tion, p.  tJI  :  Bartholin'?^  glands,  p.  iU.  Skene*s  glands,  p.  <>L  The 
rervieal  canal,  p.  04,     The  preservation  of  tissue*  p.  Olt. 


III.    THE  EXAMINATION  {Continued) 
3.  Palpation  {Coniintied) 

Befork  describing  fyrth*T  the  pathological  conditions  which 
may  be  diagnosc'd  by  the  Ijiiuaniial  touch,  it  w  ill  Ik-  well  to  n^vievv 
Borne  points  in  the  anatomy,  phyi^iology,  and  nieehanies  of  the  pelvic 
No  attempt  will  Ix*  made  to  give  a  complete  dcscriptioti 
BB  may  be  found  in  text-tooks  of  anatomy. 

Think  of  the  pelvic  as  a  box^  elowil  l^elow  by  a  flexible  diaphragm, 
the  jielvic  floor,  and  open  aljove  into  the  alxlominal  cavity*  Dirtrt 
eamniunication  l)etw(M-n  the  pelvic  cavity  and  th**  outside  worlil 
»f«teblish<?<l  through  the  lumen  of  the  Fallui>ian  tubes,  the  uterine 
ca\ity.  and  the  vagina.  The  harriprs  to  the  entrance  of  infective 
bfirteria  to  the  peritoneum  are  (1)  the  narrowings  of  the  canals 
at  the  isthmus  of  the  tidx*,  the  internal  os  of  the  uterus,  and  the 
hymen,  and  (2)  the  downward  current  of  the  s<'cretions,  partially 
maintained  by  the  cilia  of  the  lining  epithelial  ct4ls,  partly  by 
pemU^hm  of  the  tube,  and  also  by  coughing  and  straining. 

45 


41 


Pins  ICAL  EXAM  IN  AT  ION 


Tho  uterus  oeeupyiiig  the  ceiittT  of  the  pr^vif  eavity  is  susix^iKledl 
with  ite;  hm^  axis  coinciding  with  the  long  axis  of  the  pelvis  anrl  at  I 
right  anglcB  to  the  long  axii?  of  the  vagina.  An  important  point 
to  remember  is  that  it  h  suspended  and  oscillates  every  time  its 
owner  couglis,  sneezes,  laughs,  or  moves  alwut.  It  is  held  ui  jilacc 
by  certain  ligaments  to  which  it  is  attached,  by  its  connection  with 
the  vagiiia,  by  the  jjelvic  floor  supporting  the  vagina,  and  by  the 
pressure  of  the  alKlominal  contents. 

The  ligam(*nts  are  folds  of  peritoneum  containing  eonnt^ctive 
tissue,  vessels,  and  ncrvTs,  and,  in  tlie  ease  of  the  roimd  and  utero-d 


Fig.  6.— Vertical  Median  Section  of  Body.     (Kelly,) 

saeral  ligaments,  a  fi^vv  muscle  fibers.  The  broad  ligaments  are 
on  both  sfde^  with  long  attachments  to  the  sides  of  the  uterus, 
thick  at  their  lower  jwrtions,  reaching  from  the  cervix  nearly  to  the 
ftmdus  and  attached  at  their  other  ends  to  the  sides  of  the  pelvis. 
At  the  back  are  the  utero-saeral  ligaments,  attached  to  the  pt^sterior 
surface  of  the  uterus  at  the  region  of  the  internal  os  and  extending 
to  the  back  wall  of  the  pelvis  at  the  level  of  the  second  or  third 
piece  of  the  sacrum.  The  utero- vesical  eonnective  tissue  is  in  front 
and  also  the  round  ligaments,  which  begin  as  large  fleshy  cords 


I 


I 


just  in  front  of  eac-h  honi  of  the  uteru.s  and  extend  to  thr  internal 
abdominal  rings,  becoming  smaller  and  .sniaJler  a^  they  apj>roach 
their  insertion  in  the  fat  of  tlie  pul>e8. 

It  is  to  Ik?  noted  that  \vli(*n  a  winnan  is  in  the  ereet  position  (see 
Fig.  6)  the  in^sertions  and  origins  of  th<*  round  hganir^nts  He 
practically  in  the  same  horizontal  plane,  thert^fore  these  ligaments 
act  rather  as  steadying  guys  than  a.s  snpports  to  tlie  uterus.  In 
the  case  of  the  broad  tiganu*nts  they  are  thick  and  strong  in  their 
lower  jxirtions  and  really  siip[)ort.  the  eer\ix.  So  also  the  iitfTO- 
sacral  ligaments  supjiort-  the  lower  uterine  segment  and  tlii'ough 
it  the  upjjer  vagina.  The  attachments  of  the  vagina  to  the  cervix 
Hcrve  to  steatly  this  jK^rtion  of  tlic  organ  and  keep  it  in  its  profxT 
relation  to  the  pelvic  floor.     The  supporting 

tion   of  the  pelvic  floor  will  be  found  de- 

ibctl  in  more  diiail  in  the  section  on  pro- 
h\m^,  Chapter  XI\  ,  im^**  --'^' 

The  abtlominal  cavity  may  be  likened  to 
upright  cylindrical  vessel  filled  with  wat^r 

od  clogied  at  !)oth  ends  by  an  (*lastic  mem- 
b^m<^  Tlie  weight  of  the  water  causes  thr 
bottom  membrane  to  bulge  outwanl  and  the 
pre^ssun-  of  the  atmosphei*e  the  top  menibrHne 
toank  inward. 

In  the  cai*e  of  a  liv^uig  woman,  stantling 
iTiK't,  the  diajjliragm  rf^presents  the  top  mem- 
brane, theix-lvic  HfKir  tlie  lx»ttom  memhnui«% 
the  walL^  of  the  alxlomen  the  vessel,  ami  the 


Tig.  7.  —A  Vt?rtit'al 
(VhiidtT  closed  at  either 

liver^  stomach,  spl**en,  kidneys,  pancrea^s,  in-  Kud  by  an  Elaati>  Dia- 
ic0liii€9,  and  utrrine  organs  the  fluid.  The  P^*'*:*^"^  ^^^i  Filled  with 
posterior  wall  of  the  alj<lonien  is  practicafly 
immovable  like  the  walls  of  the  tube,  but  the  anterior  wall  ia  elastic 
B<1  capable  of  v^arjnng  within  wiile  limits,  not  only  the  capacity  of 
beatxiominal  cavity,  but  the  pressure  exerted  on  its  contents. 
The  contents  of  the  aUlorninal cavity  are  solid,  fluid,  and  gaseous, 
aad  the  different  structures  are  stowal  1*0  closely  together  that 
then?  i.*^  no  waste  ??[)ace  between  them.  The  jiressure  which  can 
be  e-xertinl  on  a  solid  organ  in  the  aJKlominal  ca\ity  such  as  the 
livi?r,  ha^  110  eff<H't  other  than  to  compress  it  slightly  or  cause-  it  to 
move  within  the  limits  permitted  by  its  susfxmding  ligaments. 


46  PHYSICAL  EXAMINATION 

According  to  a  law  of  jiliysics,  pressure  on  the  fluid  contents  of  a 
closed  vessel  is  transmitted  with  ecjual  intensity  in  all  directions. 
Pressure  on  the  gaseous  contents  has  no  other  eflfect  than  slightly  to 
lessen  their  volume.  The  abdominal  organs  are  supported  by  their 
ligaments  and  mesenteries,  by  each  other,  by  the  abdominal  walls, 
— the  upper  ones  by  the  ribs, — by  the  anterior  projecting  lumbar 
spine,  and  by  tlu*  shelf  of  the  false  pelvis  covered  by  the  psoas 
nmscles.  (See  Fig.  86,  page  221.)  Therefore,  when  the  woman  is 
in  th(j  erect  posture  the  weight  of  the  abdominal  contents,  minus 
what  is  assumed  l)y  the  mesent(Ties  and  the  abdominal  walls,  rests 
on  the  anterior  face  of  the  lumbar  spine  and  the  slanting  brim  of 
the  false  pelvis,  on  the  lower  anterior  abdominal  wall,  and  also  on 
the  posterior  surface  of  the  uterus  and  the  broad  ligaments  and 
through  them  on  the  i)elvic  floor.  Increased  pressure  due  to  eon- 
traction  of  the  abdominal  walls,  strainhig;  or  downward  excursion 
of  the  diaphragm,  coughing  and  sneezing;  is  transmitted  to  the 
fluid  contents  in  all  directions.  The  posterior  walls  of  the  abdomen 
are  rigid,  the  anterior  walls  are  rigid  when  contracted,  the  bony 
wall  of  the  pelvis  is  rigid,  the  pelvic  floor  is  elastic,  therefore  it 
bulges  downward,  like  the  membrane  on  the  bottom  of  the  vessel 
in  the  figure. 

If  histead  of  Ixing  in  the  erect  posture  the  woman  is  in  the 
knecvchest  position,  the  conditions  are  reversed.  Now  the  weight 
of  the  abdominal  contents  comes  on  the  diaphragm  and  the  upper 
front  walls  of  the  alxlomen,  the  p(Jvic  floor  is  depressed  inward 
like  the  upper  meml)rane  covering  the  vessel ;  when  the  vagina,  rec- 
tum, or  bla(ld(T  is  open(Hl,  air  rushes  in  to  replace  the  negative 
pressure,  thus  maintahiing  the  ecjuilibrium  of  the  atmosphere, 
fifteen  pounds'  pn^ssure  to  the  scjuare  inch  exerted  in  all  directions. 

In  this  connection  the  pelvic  circulation  is  to  be  considered. 
Enmiet  pointed  out  long  ago  (Trans,  Amer,  Gijn.  Soc.j  1887,  Vol. 
XII.,  p.  65)  that  the  veins  of  the  pelvis  are  without  valves,  and 
to  overcome  the  eff(»ct  of  gravity  their  course  is  extremely  tortuous. 
**  Moreover,  this  provision  is  necessary  that  undue  traction  be 
not  made  upon  the  vessels  with  the  change  of  position,  and  with 
th(^  incn^asing  Inilk  of  th(»  uterus  d(»pending  upon  gestation."  He 
not(»d  th(*  fact  that  if  we  draw  down  a  healthy  uterus  to  a  certain 
point  near  th(»  floor  of  tlu^  p(»lvis  and  hold  it  thcTC,  the  cervix  and 
vaginal  mucosa  become  congested  very  soon,  as  evidenced  by  the 


48 


PHYSICAL  EXAMINATION 


dark  color  of  the  tissues,  denoting  vcnOits  congestion  due  to  straight- 
ening out  of  the  tortuous  arteries  and  vein^.  f 

If  the  traetion  is  continued  until  a  portion  of  the  uterus  projects 
from  the  vagina,  the  tissues  become  l>Ianehed.  This  is  thought 
to  be  due  to  a  stretching  out  and  a  lessening  of  the  caliber  of  the 
arteries  so  that  the  blood  supply  is  cut  off.    The  connective  tissueBl 


Fig.  9,— The  Contents  of  the  PelvU  from  Above.     (Kelly,)  j 

of  the  pelvis  is  as  the  trellis  to  the  grajx^viiie,  the  pelvic  fascia 
serving  as  a  firm  support  for  tht^  whok\ 

On  each  side*  of  the  uterus  arc  the  ovaries  floating,  as  it  were, 
on  the  posterior  surface  of  the  broa<:i  ligaments,  and  the  Fallopian 
tubes  extfiiding  from  both  sides  of  the  fuutlus  uteri  to  the  outer 
extremities  of  the  ovaries.  The  ovaries  and  the  fimbriated  ends 
of  the  tubea  are  steadied  at  their  outer  ends  by  the  infimdibulo 
pelvic  ligaments,  otherwise  their  movements  are  regulated  by  the 


PALPATION 


49 


I 


the 

I     titu 

m 


movements  of  the  uterus,  broaci  ligaments,  and  the  abdomiBftl 
contents. 

The  blaiMer,  when  RIIimI,  |>ushes  th(*  uterus  and  the  ovaries  and 
the  tulx*45  backward,  ten<iing  to  cause  retroversion.  The  rectum, 
occupying  the  left  posterior  portion  of  the  pelvis,  when  distended 
tendji  to  raise  the  uterus  and  also  makes  for  retroversion,  because 
limiting  the  Imckwaixl  excursion  of  the  cervix. 

It  is  plain,  thn^,  that  the  normal  position  of  the  uterus  varies 
s^oniewhut  acconling  as  the  woman  is  stajiding  or  is  lying  down, 
it  being  nimewhat  more  antevertcil  in  the  former  and  less  ante- 
vertetl  in  the  latter,  Ix^mnse  of  the  effect  of  gravity  and  the  vary- 
ing pressure  of  the  aUlominal  contents  on  the  fundus.  Also  its 
|}06ition  a^  well  as  its  mobility  varices  according  to  the  state  of 
fuUiieJ^*'  of  the  bladiler  and  the  rectum. 

In  praclicuig  bimanual  palpation  the  following  structures  are  to 
be  felt:  thesymphvMb  pubis;  the  promontory  of  the  sacrum;  the 
utenji<:  the  ovaries;  the  Fallopian  tulx^s,  when  disi^ascd  so  that  they 
are  thickent^l  or  enlargcnl;  the  appendix  vermiformis,  verj^  excep- 
tionally and  only  when  thickened  or  enlargetl  by  dis<^mis<%  tlie  rwtum 
bladder,  onIy»  a.^  a  rule,  when  their  walls  arc  thickened, 
rare  cases  having  lax  and  thin  abtominal  parietes  a  thick- 
1  un.'ter  may  Ix^  pa]i)ate<l  at  tlie  point  where  it  crosiites  the 
ie  brim  just  outside  the  internal  iliac  artery  ant  I  the  sacro 
Bia€  joint.  A  thirkenr*d  ureter  may  be  felt  always  for  two  inches 
or  9f>  after  it  leaves  the  bladder.  In  favoraljle  ciLses  the  normal 
ureters  may  bc^  palpated  per  vaginam,  but  this  is  a  fine  point  and 
not  an  a4*complishm(*nt  of  many  physicians. 

On  ttiaking  downward  jtressure  on  tlir  alxlomen  the  |iromontory 
of  the  «acrum  is  felt  just  below  the  level  of  the  umbilicus.  Midway 
between  the  promontorj^  and  the  symphysis  pubis,  or  a  trifle  nearer 
the  symphyRiB,  the  fundus  uteri,  if  normally  placed,  is  to  he  made 
out.  In  the  erect  posture  the  external  os  uteri  is  on  a  level  with 
the  upper  margin  of  tht*  sym|*hysis  pubis;  in  the  recumbent  at- 
titude the  o»  in  slightly  higher. 

tesrlying  the  cer%ix  with  the  vaginal  finger  the  examiner  moves 

uti-ru-s  up  and  down  and  from  side  to  side,  thus  gaining  an 

idsA  of  the  mobility,  whether  normal  or  limite<l  by  past  or  present 

ioflammBtory  action  in  the  surrounding  tissues,  or  by  a  tumor  or 

t  full  bladder. 


50 


PHYHICAL  EXAMINATION 


The  uterus  may  be  displacetl  as  a  whole  downward  in  the  axis 
of  the  pelvis  (prolapse)^  or  backward  (retroposition),  or  exc(*p- 
tionally  upward.  AJterations  in  the  axis  constitute  retroversion 
(oft(*n  made  to  include  retroposition)  and  anteversion.  Lateral 
versions  are  of  little  imiwrtanee. 

Besides  the  situation,  axis,  and  mobility  of  the  uterus,  one  notes 
its  form  (abnormalities^  flexions,  and  tumors)^  its  size  (atropiiic 
or  liypertrophic),  and  its  density  (soft  in  prt^gnancy  and  septic 
conditions  and  hard  in  chronic  inflammation  and  in  many  tumors). 


Fig.  %a. — ^Norraal  Female  PeKis- 

Phjssure  on  the  uterine  bo<ly  ehcitini^  tenderness  denotes  en* 
dometritis;  and  tenderness  of  the  cervix,  endocendcitis. 

Tumors  anjTvhere  in  tlie  {x^lvis  arc  to  (k*  placed  accurately,  antl 
their  size,  form,  consistency,  and  seiLsitiveness  to  jjifasure  de- 
termined, also  their  relation  to  the  }x4vic  organs.  This  relation 
is  established  often  by  moving  the  tumor  and  noting  if  the  uterus 
moves,  or  \ice  veiisa. 

In  acute  ix^lvic  inflammation  the  alxlominal  walls  are  apt  to  be 
rigid  because  of  the  peritonismus  which  is  g(^nerally  present  Under 
tliest*  conditions  little  can  be  learned  e\eej>t  by  the  vaginal  touch. 

Exceptionally  it  is  best  to  combine  instruments  with  the  bi- 
manual touch  as  descrilM'd  in  Chapter  \TL 

(r)  The  Rectal  Touch. — This  method  of  examination  is  resoHnl 
to  io  order  to  gain  a  slightly  higlicr  reach  in  the  jx*lvis  aiid  also  in 


11 


PA Lr AT  ION 


51 


where  it  Is  inativisal)lr  Ut  nmkv  the  vaginal  tuucli,  as  in 
young  pris,  a  virgin  with  a  rigid  h>Tnen,  the  case  of  a  narrow, 
Aallow  vagina,  or  a  eongeriital  or  aetjuired  atresia  of  this  organ. 

In  making  a  reetal  examination  it  is  desirable  to  use  a  large 
Hinount  of  kibrieant  beeaiise  of  the  tightness  of  the  anus.  Tlie 
digital  examination  of  the  rectum  causers  much  more  discomfort 
to  most  women  than  the  digital  examination  of  the  vagina.  There- 
fore,  every  reasonable  de\'iee  should  Ix^  emijlnyed  to  k\sseu  the 
diHcomfort,  and  also,  unless  the  finger  is  well  lubricated,  the  anus 
wUl  grasp  it  so  tightly  as  to  interfere  \\ith  its  tactile  sc^nse.  It  is 
jrell  to  use  a  thin  rubbcT  r<^t  for  the  reetum,  removing  it  as  soon  as 
ihiit  part  of  the  examination  is  over.  Bt'f(»re  making  the  examina- 
tion the  anal  region  is  smeared  frf^'ly  with  mnco-lubricans  and  the 
left  forejfingcr  is  thoroughly  anointed  a,s  welK 

Sometimes  in  pati(*nts  who  are  annoyiHl  by  an  accumulation 
of  gas  in  the  rectum  it  is  well  to  Ir^t  this  gas  out  U^fore  making  the 
examination,  by  passiJig  a  eatht^ter  through  the  anus  Ix'fore  in- 
triKlucing  the  finger.  As  a  rule,  however,  the  presi^nce  of  gas  in 
the  rectum  facilitates  the  examination.  The  vaginal  touchy  if 
it  has  preceded  the  recta!  touch,  will  give  an  inkling  as  to  the 
cfjndition  of  the  rectum.    Thi*  prestiice  of  ft-cal  matter  calls  for 

«mema, 

'In  pa.si?ing  the  fingcT  through  tlie  aims,  nolf  tin*  tonicity  and 

stmngth  of  the  sphincter  ani.     In  the  cast*  of  hemorrhoids  or 

fissurt^.  where  there  haslx^en  long-standing  irritation  with  consiMjuent 

increased  miLscular  action,  tht*  sphincter  will  be  found  in  many 

ranes   to   be   h>'pertroplu<:d.     The  s{)hincter  may  be  weak   and 

ft     inmifficient  becaase  of  injury  re<^eived  dming  childbirth  or  by  over- 

^L^trt*tehtng  at  the  hands  of  a  surgeon,  or  in  cases  of  rectal  prolapse 

preatrophic  catarrh. 

■  A  fiasun?  by  prest*nting  a  lrK*alized  point  of  sc^nsitiveness,  hem- 
^^^rrhoids  by  giving  a  fettling  of  lumps  in  the  rectal  wall,  and  also 
^^|Kil>*pi  by  their  firling  of  ixilunculatton,  may  Ix'  detectetl  Ijy 
P  tooeh.  The  situation  of  tlie  ojM^ning  of  a  fistula  in  ano  into  the 
bowel  CAO  not  be  determined  without  the  aid  of  a  |>roh<».  Through 
tin*  thin  anterior  rectal  wall  the  <'xamining  fingt^r  makes  out  the 
c«^TX^  the  basc*s  of  th*^  broad  ligaments,  and  thi'  ntrro-sncral  liga- 
Ru*fiiB.  By  raising  the  utenis,  these  ligaments  are  put  *>n  the 
stretch  and  an  i<lea  may  be  obtained  as  to  their  relative  length 


52 


PHYSICAL  EXAMINATION 


and  thickness.  The  posterior  wall  of  the  nti^rus  is  vfry  accessible 
through  the  rectum. 

The  ovaries  and  tubes  if  prolapsed  may  Ih^  i)aiimted  advanta- 
geously by  the  rectal  touch, 

Thruugli  tlie  posterior  wall  of  the  rectum  the  coccygeal  and 
sacral  vertebra^  may  be  felt,  and  fractures  and  dislocations  of  the 
coccyx  determined.  Pain  caused  by  pressure  on  the  coccyx  may 
mean  coecygodynia,     (See  Chapter  X,,  page  l.>9.) 

Infiltrations  or  new  growtlis  iii  tlie  recto-vaginal  septum  are 
to  f>e  mapixxl  out,  as  to  size,  situation,  consistency,  and  sensitive- 


V 


.^ 


Fi«.  lU.  — Haifa  Fi'jujilu  Ft  l\  j  ,  >iMA\iui:  Am>.iljiliiy  uf  louttnLstii  i*:ilpiaiim. 

ness,  by  combined  vaginal  and  rectal  touch,  the  finger  of  one  hand 
being  ui  the  vagina,  and  the  forefinger  of  the  other  hand  in  the 
rectunu  The  (jresence  of  new  growths  and  strictures  in  the 
rectum  is  diagiioscfl  by  the  rectal  touch. 

Too  great  care  (*an  not  be  exercised  in  washing  the  hands  before 
changing  from  a  rectal  to  a  vaginal  examination  anrl  vice  versa, 
IrMH^ause  of  the  danger  of  transferring  inft^cth't^  matter  from  one  organ 
to  the  other.  In  the  case  of  acytu  inhMnive  inflanunation  of  the 
vulva  and  vagina,  it  is  wiser  not  to  examine  tht*  rectum  at  all. 
Often  the  rt^ctal  examination  may  be  tleferred  as  well  to  a  later  date. 


In.     n  — Tlif  Siniv  IV>8iiinri. 

for  oxplomtiofi  of  the  ('idHlixsa*'  n{  Dny^las  and  its  contents,  than 
by  ihr  bimajiual  va^ino-abdoiniiial  toiicli. 

I%ital  exploration  of  the  blaildiTisan  iinjustifiahlr  proccilure,  as 
all  the  infomiation  ol^tainetl  liy  touch  may  1k^  ^ainnl  i>y  a  si>CTuluni 
fxatuiiiation  ami  by  vaginal  and  n^ftal  tonrh.  The'  danger  of 
ineontinrace  of  urine  is  too  gn^at.  to  justify  introducing  the  finger 
through  tin*  ur«*fhra,  no  matter  ln»\v  i^niall  the  finder  may  h\ 

(e)  Gynecological  Positions  other  than  the  Dorsal  Position. — 
Bi!!%ick*s  the  tlorsal  position  wliich  has  Ixn-n  ileserilx^d  ah"<^tuiy,  there 
an»  ae^Tral  other  fxis^itions  ijito  which  the  patient  is  put  for  pitf- 
poees  of  examination. 


54 


PHYSICAL  EXAMINATION 


They  are: — the  Sims,  the  knee-chest,  the  Hthotomy,  the  raised 
pelvis,  and  the  standing  positions. 

The  Sims  position  is  not  so  frequently  used  now  as  in  the  years 
following  the  invention  of  the  Sims  speculum.  Still,  it  is  of  great 
service  both  for  the  use  of  the  speculum  and  other  instruments, 
for  practicing  the  bimanual  touch,  and  for  examination  of  the  anus 
and  rectum.  For  some  reason  not  altogether  clear,  the  illustra- 
tions hitroduced  into  all  but  one  or  two  text-books  on  gynecology 
to  show  this  i)osition,  do  not  figure  it  correctly  as  it  was  devised 

by  Sims  or  as  it  is  used  in 
the  hospital  where  he  did 
his  work,  the  Woman's 
Hospital  in  the  State  of 
New  York.  As  commonly 
shown,  the  patient  is  lying 
on  her  left  side  with  thighs 
only  partly  flexed  on  the 
abdomen,  hi  the  middle  of 
a  long  table;  her  head  is 
generally  on  the  left  side 
of  the  table,  her  hips  in  the 
middle,  and  so  far  from  the 
bottom  edge  that  the  gen- 
itals are  entirely  inaccess- 
ible for  examination. 

Suppose  we  have  finished 
with  the  dorsal  position 
and  wish  to  put  our  pati(»nt 
in  the  Sims  position.  Pull- 
ing the  sheet  off  and  holding  it  in  front  of  her  we  give  her  a  hand 
and  ask  her  to  stand  in  the  chair  at  the  foot  of  the  table.  Then 
we  pull  out  the  little  slide  for  a  foot  rest  in  the  right-hand  lower 
comer  of  the  table  and  place  the  pillow  for  the  head  diagonally 
about  midway  along  the  right  edge  of  the  table.  Now  we  ask  her 
to  raise  her  skirts  and  to  sit  on  the  left-hand  comer  of  the  table, 
sitting  as  far  over  to  the  left  as  she  can  and  tuming  on  her  left 
side  and  drawing  up  her  knees  as  she  lies  down.  Throw  the  sheet 
over  the  hips  as  soon  as  she  gets  down.  N(»xt  ask  her  to  put  her 
left  arm  ov(t  the  left  edg(»  of  the  table  and  h(»lp  her  to  do  it. 


Fig.  12. — Diagram  of  the  Sims  Position. 


PALPATION 


55 


See  that  her  ht^ti  ij^  on  ilir  pillow  on  the  light  side  and  that  she 
is,  as  it  were,  tloubled  up  like  a  jack-knife.  Then  the  physician 
stands  on  the  left  of  the  table  facing  the  patient's  hips,  pulls  them 
(asking  at  the  same  time  for  the  patient's  assistance)  to  the  left, 
until  the  back  of  the  sacrum  h  even  with  the  left  edge  of  the  table, 
and  the  lower  margin  of  the  buttocks  corresjionds  witli  the  lower 
etige  of  the  table.  The  fi^et  are  now  on  tlic  foot  rest,  oi',  in 
ciefault  of  this,  on  the  hack  of  a  chair  padded  with  a  foldefl  blanket, 
ar  on  a  table.  The  upjK-r,  the  right  kntn^  is  advance<l  a  httle 
beyond  its  fellow,  anfl  the  inner  edge  of  the  sole  of  the  right  foot 
rt^ts  on  the  instep  of  the  U'ft  foot. 

A  fresh  towel  opened  out  is  made  to  cover  the  lower  buttoek 
and  thigh  by  tucking  one  en<i  info  the  drawers  behind,  and  carry- 
ing thi*  other  end  lietween  the  thighs  in  frcmt,  Th*^  (wc  end  Ix'low 
is  tiickwl  under  the  covering  of  the  table.  The  upjx'r  l>yttoc*k 
and  ttiigh,  the  legs  and  feet»  and  the  rest  of  the  Ixxly  are  covered 
by  the  shef*t. 

In  this  jxjsition  the  jK'Ivis  is  inclined  at  a  slight  angle  to  tht^ 
table^  the  ablominal  contents  fall  away  from  the  pelvis,  leaving 
the  j>el\ic  organs  frt^e  from  pressure;  the  alxloiuinul  walls  are 
rr-laxotl  and  the  vagina,  Imllooned  by  air  admitted  by  the  speculum, 
can  bo  most  easily  inspected. 

It  is  difficult  to  put  very  stout  women,  or  patients  with  large 
abdominal  tumors,  in  this  position  an*!  in  thesc^  cases  the  Sims 
position  is  of  less  value  than  in  thiimer  subjiHi'ts, 

The  injfx>rtant  pobits  are  to  get  tlie  patient's  back  on  a  level 

th  the  left  <*<lge  of  the  tal>!e  and  the  heatl  on  the  right  edge  of 
:he  table.  Unless  the  patient  is  fait  in  the  correct  position  it  is  of 
no  value  what<»ver,  Trik'ss  the  tliighs  an*  shaiply  flexed  on  the 
abrlomen  antl  the  hips  are  at  the  edge  of  the  table,  the  pliysieian 
can  neither  look  into  the  vagina  nor  make  manipulations  to  ad- 
\*antage. 

The  bimanual  vaginoabdominal  or  reeto-abdomina!  touch  is 
made  with  the  patient  in  the  Sinis  (xjsition  by  introducing  the  left 
f  ''  r  in  either  vagina  or  rectum  and  the  right  hand  between 
t  r  i_  tis^  a^jking  the  patient  to  raise  her  right  tliigh  until  the  hantl 
is  in  place  and  then  letting  it  dro)>  again. 

Ilie  Sini.s  position  is  useful  also  for  palpating  uterine  antl  ova- 
rian tumors;  \iith  the  patient  in  this  position,  relaxation  of  the 


56  PHYSICAL  EXAMINATION 

abdominal  walls  may  Ix^  obtaincil  often .  when  it  can  not  be  with 
the  patient  m  the  doi-sal  position. 

The  knee-chest  pomiion,  or  knce-elbjw  position,  as  it  is  some- 
times called,  is  anotlier  gynecological  position  commonly  ^wougly 
figured  in  the  text- books.  The  patient  stands  in  the  chair  at  the 
foot  of  the  examining  table  facmg  the  table.  She  raises  her  skirts 
in  front  an<l  (ilaces  one  knee  near  one  comer  of  the  table,  the  other 


4 

il 

Fm.  13.— The  Ivnee-Chest  Position. 

knee  follows  and  takes  its  place  at  the  opposite  comer  of  the 
table.  Then  she  lx*nds  fonv^ard  and  places  her  hands  in  the  middle 
of  the  table  while  the  physician  throws  the  sheet  o\^er  her.  The 
feet  and  legs  are  left  projecting  over  the  table's  edge,  but  the 
position  is  not  uncomfortable,  for  all  the  weight  comes  on  the 
knees  and  hands.  Now  the  patient  is  on  her  hands  and  knees  on 
the    table.     The  physician   folds  a  gooil-sized  pillow    once  and 


PALPATION 


57 


place's?  it  in  the  tiiidiilc  of  tlu*  tabic.  The  imtient  is  askecl  to  place 
her  head  and  chest  on  the  pillow  with  her  face  to  one  side,  letting 
het>!e]f  down  on  to  her  elbows  as  she  does  so.  The  physician  next 
goes  to  the  foot  of  the  table,  throws  the  skiits  abive  the  hipH 
under  the  sheet  and  drapes  each  thigh  with  the  sides  of  the  sheet. 
Note  now  whether  the  thighs  aj*e  vertical.     They  are  apt  not  to 

■  be,  as  tlie  fjatient  generally  throws  her  chest  too  far  forward,  thus 
^^^elaiiting  the  thighs.  If  they  are  not  vt^rtical  tliey  an*  t'asiiy  niade 
^^■d  by  asking  the  patient  to  move  her  chest  back  a  little  as  the 

■  pillow  is  niove<.l  for  her  in  the  same  direction. 

I         The  knee^'hest  position   is  rnost  useful  ff>r  spcHniluo!  examina- 


ul'   \  ti  \v\  Shnwiu^   WrtjcaJ  Thighs. 


tiofii?  of  the  vagina,  bladder,  and  rectum,  tfie  MlMlominal  pressure 
bf'ing  n'moved,  and  the  viscus  in  whicli  the  sp4*(*ulym  is  plannl 
fieing  Jmllooned  hy  the  atmospheric  pressure  admitted  by  opening 
the  t*xtc*mal  oriBcc. 

To  replace  a  retrovt^rteii  or  retroflexe<l  incarcerated  uterus, 
or  an  incarcerated  tumor  of  the  pehns,  often  necea^ary  to  est  a  Wish 
a  dia,i^nsi.**,  the  knee-chest  [msition  is  invaluable. 
Tfw  lithotomy  ptmtwn  is  the  dorsal  ix)sition  with  the  thighs 
ced  on  the  abdomen.  The  jKisition  is  maintained  by  leg  holders, 
nf  the  Von  Ott,  Robb,  or  the  Clover's  crutch  patterns,  bj^  different 
foftDs  of  slings  holding  the  flexed  thighs  to  the  shoulders  of  the 


J 


58 


PHYSK  A  L   liXAM  1  NAT  1(  >N 


patiriit  wUh  .straps,  or  hy  Ir^  iKiIdrrs  jitt ached  to  tlir  o|jmitiiigj 
table.      The  ijatient  is  placeii  hi  the  lithotoiiry  positioii  just  aa| 
hi  the  (lorsiil  jjosition,  with  the  addition  tliat  the  thi*rhs  are  kept 
Hexed   by  some  deviee.     Without  any  a[>[)aratys  whatever  it  is 
posvsiblo,   and   often   convenient,   esp^x-ially   in   short   operattonSyfl 
such  as  curetting,  for  one  assistant  to  hold  bioth  legs  with  one 
hand  and  Imve  tlie  otlier  hand  free  to  assist  tlie  physician.     To 
do  this,  the  assistant,  generally  a  nurse^  places  herself  on  the  left 
side  of  the  table  (the  patient's  right  side),  facing  the  physician,  who  < 


is  seated  in  the  chair  at  the  foot  of  the  table.  She  reaches  across  the 
patient's  flexed  limbs  with  her  left  arm,  letting  the  right  knee  rest 
m  her  left  axilla  and  grasping  the  left  If^g  with  her  left  hand.  Thus 
her  right  hand  is  free  to  hold  instruments  for  the  doctor. 

The  lithotomy  position  is  used  for  examtnatiojis  under  etlicr, 
for  operations,  and  for  investigations  wh*»re  it  is  ntressary  to 
scrub  up  atid  asc])ticize  tlie  vulva  and  surrounding  regions. 

The  raised  pelvis  jx)sitimi,  us<h1  only  in  eystoscopic  exaruina- 
tions,  is  an  exaggerated  lithotomy  position.  It  is  best  obtainetl 
on  a  table  which  lias  a  mecliaidsni  for  the  Trendelenburg  posture. 


PALPATION 


59 


I 


but  may  tie  wctutimI  by  placing  a  liUix^H^k  uv  hiinl  ctishinns  rdvrnMl 
with  towi'Ls  under  llu^  satTuni,  so  that  tlu*  [H'ivis  is  plcvatt'd  alxjut 
trn  inchoii  above  the  level  of  the  table,  the  k^gs  lieing  hM  Ijy  a 
Uobb  leg  holder  or  by  an  assistant  standing  on  a  stool  or  I>ox, 
This  pa-^ition  tilt?;  the  pelvis  backward  and  removes  abdominal 
I>R*ssure  from  the  bladder. 

The  standing  position  is  of  occasional  use  in  determining  the 
ilcgree  of  prolapse  of  the  uterus  and  Viiginal  walls  when  full  al>- 
doruinaJ  pressure  is  exerted,  also  the  axis  of  the  uterus  under  these 
(nnditions,  and  the  holding  power  of  a  pessary. 


Fio.   Hi,— Tilt-  liiiised  Pelvis  Position. 

The  patient  stands  facing  the  physician  with  her  right  foot 
rufting  on  a  round  of  a  chair  eiglit  or  ten  inches  from  the  Hoon 
The  physician  kiicels  on  his  left  knee  in  front  of  her,  or  sits  in  a 
low  chair  restuig  his  left  ellniw  on  his  left  knee.  He  anoints  his 
left  forefinger,  and  j?temlying  himjs4*lf  with  his  right  hanti  on  her 
Mt  hip,  finds  the  vulva  by  sw^ee|>ing  the  anointed  middle  finger 
of  hi.H  left  hand  over  the  anal  n^gion,  and  then  introduces  the  fort*- 
finder,  ju8t  a^  in  the  vaginal  examination  in  the  case  of  the  dorsal 
fjOHition*  Having  the  patient  bear  down  or  cough  gives  an  itiea 
to  the  excursion  of  the  uterus  with  forcetl  expiration. 


COLLECTION  OF  DLSCHARGES  AND  TISSUES 


61 


Acetonemiai  a  fonn  of  intoxication  with  acetone  occurring  in 
diabetes,  in  infectious  fevers,  in  intestinal  fcmicntation,  in  gen- 
t^ral  sepsis,  and  sometimes  following  g>mecologieal  o]>erations, 
may  be  distinguished  by  the  sweetish  odor  of  the  l^rcath^ 
described  as  like  that  of  a  pippin  apple. 

5,  The  Collection  of  the  Disch arches  .\nd  Tissues  for 
Microscopic  Examination 

Ifiaterials  Needed.— L  Half  a  dozen  fitisolutely  clean  cover 
gla^^'H.  2.  A  few  euJture  tubes  of  hydrocele  agar  or  blo<>d  yeriini 
(furnished  by  the  pathologist),  3.  Platinum  wire  loo|).  4.  Alcohol 
lamp.  5.  I^ng-handled  i^harp  knife.  6.  Loug-hantlled  f^hari> 
pointt*<J  scissors.  7.  Uterine  tetiaculutu.  8.  Uterine  dressing  for- 
ceps. 9.  Needle-holder,  curveci  neetUe,  and  catgut.  10.  Gauze 
packing.     11.  Small  bottle  of  ten-per-cent  formalin. 

Bartholin's  Glands. — If  the  dis(*harge  from  the  glands  of  Bar- 
tholin is  to  b*  collected  for  examination  for  gonocoeci  or  tubercle 
t»acilli,  the  labia  are  sc^jjarattnl  and  the  vulva  is  wiped  dry  with 
sterile  cotton  i>leilgets.  Grasp  the  gland  to  l>e  investigated  be- 
twfX'n  the  thumb  and  forefinger,  makt*  gentle  pressure.  an<l  transfer 
the  dischai-ge^  which  exudes  from  tlie  innutli  of  the  gland's  tlut-t.  to 
a  cover  glaa^  by  means  of  a  platinum  wire  loop  or  uterine  applicator 
which  ha.s  Inx^n  passed  piTviously  througli  the  flame  of  an  alcohol 
lamp.  Place  a  clean  cover  glass  upon  the*  first  oiu^  press  the  two 
gently  tfjgi'ther  to  spread  the  discharge  evenly,  sliile  the  two  a|>art, 
and  allow  to  dry.  The  dry  cover  gla.sse8  may  then  Ik*  reajjplied 
face  to  face  and  held  together  by  an  elastic  tmnd.  They  are  then 
placet!  m  an  envelope  which  is  labeled  as  follows: — 

Name  of  patient: 

Date: 

Source  of  material: 

Examine  for  (organism): 

Sent  by  Dr. 

The  preparation  properly  labeled  is  then  sent  to  the  pathol- 
ogist for  examination. 

Skene's  Glands.— The  orifice  of  the  uj*ethra  and  the  introitus 
vaginir  are  wiped  dry  with  sierile  i-otton  pledgets.  Introduce  the 
finger  bto  the  vagina  and  make  gentle  pressure  from  above  do^Ti- 


62  PHYSICAL  EXAMINATION 

ward  along  the  course  of  the  urethra.  As  the  ducts  of  Skene's 
glands  open  mto  the  urethra  just  inside  the  urethral  labia,  any 
discharge  from  these  ducts  will  contain  a  certain  admixture  of 
urethral  discharge  also.  The  urethra  can  hardly  become  infected 
without  accompanying  infection  of  Skene's  glands,  but  this  mixture 
with  urethral  discharge  is  unimportant  from  a  clinical  standpoint. 
If  it  is  essential  to  examme  the  discharge  from  Skene's  glands  apart 
from  that  from  the  urethra,  then  the  latter  canal  must  be  walled 
off  with  a  small  cotton  pledget  and  pressure  made  only  over  Skene's 
gland.  Transfer  the  discharge  obtained  to  cover  glasses  as  de- 
scribed under  Bartholin's  glands. 

The  Cervical  Canal. — The  patient  is  placed  in  the  Sims  position 
by  preference,  although  the  procedure  may  be  successfully  carried 
out  in  the  dorsal  position.  A  speculum  is  introduced  and  the 
vagina  cleansed  with  sterile  cotton  and  water  and  then  dried  with 
dry  cotton.  A  good  exposure  of  the  cervix  can  usually  be  obtained 
without  the  use  of  a  tenaculum.  The  use  of  a  tenaculum  is  often 
accompanied  by  bleeding  which  may  contammate  the  cervical 
discharge.  Sometimes  it  is  necessary  to  draw  the  cervix  down 
with  a  tenaculum.  In  this  case  the  instrument  should  be  firmly 
fixed  at  the  first  attempt  and  held  in  place.  A  sterile  tampon 
screw  is  most  useful  in  obtaining  cervical  discharge.  The  instru- 
ment is  introduced  into  the  cervical  canal  not  beyond  the  internal 
OS  and  twisted  mitil  some  of  the  discharge  has  been  caught  in  the 
threads  of  the  screw.  WTiether  obtained  with  the  screw  or  with 
the  platinum  wire  loop  the  smear  is  made  as  described  in  the  case 
of  the  glands  of  Bartholin  and  Skene. 

Cultures. — If  cultures  for  the  purpose  of  obtaining  a  bacterial 
growth  from  a  discharge  are  to  be  made,  the  culture  tubes  are 
used.  Collect  a  drop  of  the  discharge  on  the  sterile  small  wire 
loop  which  comes  with  the  tube  and  smear  it  over  the  slanting 
surface  of  the  material  in  the  tube.  Replace  stopper,  label  care- 
fully, and  return  to  the  pathologist.  It  is  possible  to  introduce 
the  small  wire  loop  into  most  cervical  canals  without  dilatation,  and 
it  is  much  better  to  take  the  culture  or  smear  without  dilating 
the  canal,  lx)cause  in  the  process  of  dilating  the  discharges  are 
partly  removed  and  mixed  with  blood  and  tissue. 

Removal  of  Tissue  from  the  Cervix  for  Examination.—- The  Sims 
position  usually  offers  the  best  exposure  of  the  cervix  for  the 


COLLECTION  OF  DISCHARGES  AND  TISSUES  63 

removal  of  pieces  of  tissue  for  examination.  In  removing  a 
suspicious  piece  of  tissue  for  microscopic  examination  it  is  wise 
to  cut  out  some  of  the  apparently  healthy  tissue  as  well  as  the 
disi'asecl  portion,  for  it  occasionally  happens  that  the  pathologist 
receives  nothing  but  necrotic  tissue  and  can  form  from  it  no  diag- 
nosis whatever.  A  raw  surface  left  by  removal  of  tissue  should  be 
closed  by  suture  or  tamponed  until  all  bleeding  has  been  checked. 
Tissues  removed  by  the  curette,  scissors,  or  knife  for  the  purpose 
of  diagnosis,  are  to  be  plunged  intact  and  immediately  into  a  ten- 
per-cent  solution  of  formalin  in  water;  then  they  are  properly 
labeled,  and  sent  to  the  pathologist. 


CHAPTER  VI 
THE  PHYSICAL  EXAMINATION  (Continued) 

III.  The  examination  (continued) :  6.  Inspection  of  the  abdomen,  p.  64. 
Method  of  performing  it,  p.  65.  Appearances  to  be  noted,  p.  65.  En- 
teroptosis,  p.  67. 

7.  Palpation  of  the  abdomen,  p.  68.  Method  of  performing  it,  p.  69. 
Points  to  be  determined  by  palpation,  p.  69.  Palpation  of  the  kidneys,  p. 
70. 

8.  Percussion  of  the  abdomen,  p.  71  ;  Auscultation  of  the  abdomen,  p. 
72  ;  Mensuration  of  the  abdomen,  p.  74  ;  Gauze  records  of  abdominal 
tumors,  p.  74;    The  X-rays  in  diagnosis,  p.  76. 

III.    THE  EXAMINATION    (Continued) 

6.  Inspection  of  the  Abdomen 

Attention  will  be  directed  to  the  abdomen  to  a  greater  or  a 
less  degree  according  to  the  nature  of  the  disease  present  in  any 
given  instance.  In  the  case  of  late  pregnancy,  and  of  tumors  of 
abdominal  evolution,  whether  originating  in  the  pelvis  or  not, 
investigation  of  the  abdomen  is  of  chi(»f  importance. 

In  suspected  uterine  disease  the  vaginal  and  bimanual  examina- 
tions usually  precede  the  examination  of  the  alxlomen.  In  the 
case  of  a  large  abdominal  swelling  the  abdomen  is  first  inspected. 

For  the  examination  of  the  abdomen  it  is  not  so  necessary  that 
the  pati(mt  should  lie  on  a  hard  surface  as  in  the  case  of  the  vaginal 
examination.  However,  the  table  is  mos1;  convenient  for  the 
physician  because  he  can  stand  up  and  make  his  ins{Xiction,  palpa- 
tion, percussion,  and  mensuration  when  in  a  position  comfortable 
to  himself;  not,  as  in  the  case  where  the  patient  is  on  a  low  bed  or 
couch,  with  bent  back  and  strained  muscles,  conditions  which  are 
not  conducive  to  most  careful  investigation.  The  patient  on  a 
table  is  comfortable  enough  for  the  brief  time  required  for  the 
examination. 

All  the   patient^s   clothing  has  been  loosened  and  the  corsets 

64 


mSPETTtON  OF  THE  ABDOMEN 


remove<I,  an  previously   (li*stTibt*d,     Tlie  8lu*et   eovei's  tla^   legs, 

■  thigb^y  antl  pubic  rvgioii.     Tlu*  raisiMl  skirts  covlt  the  chest,  or, 

if  the  skirt^s  have  Ix^cn  renio veil,  another  siieet  is  useil  for  this  pur- 

To  ijivestigate  the  alxlooien  to  the  best  advantage  the  pat  lent  ^s 
head  j^hould  bv  miR^d  a  httlc  on  a  pillow  and  the  thighs  should  bc^ 
slightly  flexed.  Too  much  fl(^xing  of  tlie  thighs  or  raising  the  head 
and  thorax  high  will  decrease  the  portion  of  the  alxlomen  available 
for  cxaDiinatioru 

For    purposes   of  deseri|>tion    the    alKlomen    may   be    *lividcd 


f 


J:' 


£n«ifomj 
rartilagp 


Mariiii  of  rihi  - 


Owt  oi  ilium  - 


Spine  of  piibe» 

Flo.   18. — Tht*  AlMlonien  Dividtil  into  Quadrants 
and  the   Bony   Landmarks  Indicated. 

•^itrarily  into  four  regions,  liv  two  lines,  one  a  vertical  fine  pans- 

iig  tliruugh  the  ensifonn  cartilage,  the  umbilicus, and  the  syrnphysis 

ibis,  ancl  the  other  passing  through  the  umbilicus  at  right  angle?® 

to  the  vertical  line.     The  four  regions  &o  made  may  he  calletl  the 

right  upiKT  <)uadrant,  the  right  lowfT  quadrant,  the  left   u}iper 

rqumtrant,  and  {hv  left  hnver  r|iiadrant. 

On  oJj^erving  the  ahlonienone  notices  syiiimetry  or  as}7nmetry, 
listention  or    retraction,  increased  or  diminishvd  motion  of  (he 
^minal  w^alls  on  res|nratioii^  and  the  ap|»eamnce  of  the  skin. 


66  PHYSICAL  EXAMINATION 

To  detect  symmetry,  stand  at  the  foot  of  the  examining  table  and 
look  at  the  abdomen  from  below.  Tumors  of  the  ovary  as  well  as 
tumors  of  the  kidney  are  apt  to  cause  asymmetrical  enlargement 
of  the  abdomen;  whereas,  tumors  of  the  uterus  and  ascites  more 
commonly  produce  symmetrical  enlargement.  One  notes  bulging 
in  the  flanks  and  a  flattening  of  the  anterior  aspect  of  the  abdomen 
due  to  ascites,  or  to  lax  abdominal  walls,  with  or  without  an  abnor- 
mal amount  of  fat  in  the  panniculus  adiposus. 

A  tumor  rising  from  the  pelvis,  unless  of  great  size,  is  usually 
outlined  by  the  abdominal  walls.  In  ovarian  cysts  the  abdomen 
is  irregularly  ovoid  in  shape  with  its  point  of  greatest  protuberance 
below  the  umbilicus,  and  there  is  no  bulghig  in  the  flanks.  In 
the  case  of  multilocular  cysts  the  loculi  may  be  distinguished  by 
sight  in  exceptional  cases  through  a  thin  abdominal  wall,  so  nodules 
of  a  malignant  growth  in  an  ovarian  cyvSt  can  sometimes  be  dis- 
tinguished by  the  eye.  Large  multiple  fibroids  also  show  occasion- 
ally through  the  skin  as  lumps  of  irregular  shape;  an  interstitial 
fibroid  forms  a  protuberance  of  a  smoother  outline  that  is  generally 
situated  in  the  median  line. 

Observe  the  movements  of  the  abdominal  walls.  The  normal 
movements  on  inspiration  and  expiration  extend  over  the  entire 
surface?  from  ensiform  to  ])ubes.  In  cases  of  large  tumors  springing 
from  the  pelvic  ca\aty  the  movement  is  confined  to  the  epigastric 
region  if  the  distention  is  great,  also  if  there  are  adhesions  between 
the  tumor  and  the  parietes  there  may  be  motion  only  in  this  region. 
Sometimes,  when  there  are  no  adhesions  present,  the  abdominal 
wall  can  be  seen  to  glide  up  and  down  over  the  surface  of  a  tumor 
of  moderate  size. 

Waves  of  peristalsis  in  the  intestines  may  be  noted  in  a  patient 
with  thin  flaccid  walls  and  retracted  abdomen,  also  pulsations  of 
the  abdominal  aorta.  In  pregnancy  the  situation  of  greatest  in- 
tensity of  fetal  movements  may  be  observed. 

Separation  of  the  recti,  due  to  distention  of  the  abdomen  during 
previous  pregnancies,  often  leaves  a  ventral  hernia  through  which 
a  tumor,  the  i)regnant  uterus,  or  the  abdominal  contents  may 
protrud(\  Palpation  of  the  abdominal  and  pelvic  organs  is  ren- 
dered most  easy  in  these  cases. 

Th(»  appearance  of  the  skin  of  the  abdomen  is  of  interest  as 
showing  discolorations  from  blisters  and  counterirritants,  indica- 


INSPECTION  (i¥  THE  ABDOMEN 


67 


K 


lions  of  previous  treatment,  also  the  presence  of  edema  or  skin 
di^Msases.  Krjlargement  of  the  superficial  veins  huHcates  preasurr* 
on  the  deeper  vessels.  Excessive  i!i«tention  of  thf*  af>d()!n<^jj 
renders  the  skin  white  and  glossy  in  appearance,  whema^s,  when  the 
walk  aix:^  lax,  the  skin  has  a  shriveled  or  puekered  look. 

The  linea^  aibicantes,  red  and  purple  when  ntTent,  and  white 
and  glistening  w^hen  old,  are  to  l»e  looked  for  especially  over  the 
flanks.  They  indicate  previous  stretching  of  the  skin»  but  are  not 
pathognomonic  of  pregnancy,  as  they  occur  in 
virgins  who  have  grown  rapidly  and  then  lost 
subeutAneous  fat. 

Pigmentation  of  the  linea  alba  (linea  nigra)  and 

increa.se  of  pigment  atout  the  umbilicus  and  lower 

bdomen  occur  in  some  women  during  a  first  preg- 

ey.  This  pigmentation  persists,  but  is  of  no 
diagnostic  importance  in  a  subst^quent  pregnancy. 

When  the  patient  is  sick  in  lx*<!  with  peritonitis, 
the  characteristic  way  in  which  she  holds  herself, 
with  knees  drawn  up  to  relieve  all  stram  on  the 
abdominal  parietes,  is  to  be  noted. 

Enteroptosis. — In  some  cases  it  is  advantageous 
to  put  the  i»atient  in  the  standing  position  for  the 
pur]>ose  of  ins|x*cting  the  ab<!omen:  especially  is 
this  deirfrable  in  suspected  ptosis  of  the  akionii- 
nal  \iscera,  a  condition  often  associated  ^^ith 
uterine  disease. 

Here  w^e  must  inspect  not  the  abdomen  alone, 
but  the  entire  tmnk.  The  patient  stands,  first,  facing  the  phy- 
sician, entirely  nude  except  for  a  sheet  held  by  a  nurse  draping 
the  lower  limbs  and  pubic  region.  Then  she  stands  so  that  he 
sees  her  in  profile.  In  typical  enteroptosis  one  notes  a  long,  nar- 
row thorax,  with  flat  and  sunken  epigastric  rei::iori.  The  waist  is 
kmgf  the  afxiomen  is  prominent,  the  shouldr  rs  are  roundetl,  and 
wboi  aeen  in  profile  the  lower  back  is  nearly  flat  instead  of  pre- 
wmtmg,  as  nonnally.  a  forward  cur\T,  with  shoulders  and  hips  well 
haelc  and  spine  bent  foi'ward  in  the  lumbar  region.  There  is  gen- 
crally  an  abe^nce  of  a^lijiose  t ksue  in  these  patients  and  the  muscles 

apt  to  be  deniler  and  flabby. 


Flo.  19.— The 
Body  Pose  io 
Entc»ropto«i«. 


1 


68  PHYSICAL  EXAMINATION 


7.  Palpation  of  the  Abdomen 

To  palpate  the  abdomen  successfully,  the  patient  should  be  pre- 
pared as  for  hispection,  that  is,  in  the  dorsal  position  with  the  head 
slightly  raised  on  a  pillow,  all  clothing  loosened,  the  feet  supported, 
and  the  pubic  region,  thighs,  and  legs  covered  by  a  sheet.  The 
physician,  standing  on  the  patient's  right,  places  both  hands, 
wanned,  and  with  finger  nails  cut  short,  on  the  abdomen.  No 
abrupt  or  rapid  movements  should  be  made,  and,  for  the  purpose  of 
distracting  the  patient's  attention  and  thus  favoring  relaxation, 
it  is  ad\'isable  at  this  juncture  to  ask  some  question  as  to  the  health, 
not  directly  referable  to  the  abdomen. 

By  care  and  patience  the  tendency  of  the  abdominal  muscles 
to  contract  when  stimulated  by  manipulation  may  be  overcome. 
Oftentimes  more  than  one  sitting  is  necessary  to  accomplish  this 
result,  and  in  this  event  the  diagnosis  must  be  held  in  abeyance 
until  after  a  second  examination.  It  is  better  to  make  two  or  more 
attempts,  except  in  urgent  cases,  rather  than  resort  to  an  examina- 
tion under  an  anesthetic,  because  with  increasing  experience  the 
physician  learns  an  added  amount  from  each  palpation,  and  hav- 
ing gained  the  patient's  confidence  and  treating  every  case  accord- 
ing to  her  individuality,  he  is  able  more  frequently  to  dispense  with 
an  anesthetic. 

The  utmost  gentleness  should  obtain  always.  The  harder  the 
pressure,  the  greater  the  resistance  of  the  abdominal  walls  and 
the  greater  the  blunting  of  the  physician's  tactile  sense.  Further- 
more, it  has  happened  several  times  in  the  experience  of  the  writer, 
that  a  student  novice  has  ruptured  a  thin-wallal  or  necrotic  ovarian 
cyst  or  a  circumscribed  collection  of  peritonitic  fluid,  by  too  vig- 
orous palpation. 

A  thin,  relaxed  abdominal  wall  permits  of  palpation  of  the 
promontory  of  the  sacrum,  and  the  pulsations  of  the  abdominal 
aorta  are  to  lx»  felt  distinctly.  The  anterior  superior  spines  and 
the  crests  of  the  ilia,  the  symphysis  pubis  and  the  borders  of  the 
ribs,  body  landmarks,  are  always  to  \yc  made  out.  Thick  and 
tense  alxlominal  walls  interfere  with  palpation. 

It  is  well  to  have  a  definite  system  to  follow  in  palpating  the 


PALPATION  OF  THE  ABDOMEN 


69 


abduiueiL  Begin  with  thr  hnwv  «iuatlraet8  and  prcn'oetl  to  the 
Upper  quadmnt.s,  (See  Figure  18,  page  65.)  By  making  firni 
but  gt*ntle,  dee|)  |)res,sure,  the  (latient  at  the  same  time  taking  a 
tlt\'p  lireath,  the  hands,  flat  on  the  alxlonien,  are  l*rought  togi^her 
and  a  fold  is  graspeil  l>etween  them  so  that  an  estimate  is  formed 
of  the  thicknet^s  of  the  alxlominai  walls  and  their  degret*  of  tension. 
Avoid  as  far  as  j)ossil)Ie  iligging  into  the  flesh  with  the  tips  of  the 
fingers,  UBing  instead  the  palmar  surfaces  of  the  last  phalaogcs, 
the  location  of  the  traineLl  tactile  sense. 

We  may  leam  by  paljmtion,  of  the  presence  of  a  tumor,  also  its 
situation,  size^  shape,  mobility,  consistc^ncy,  and  point  of  attach- 
ment. We  determine  a  |)ouit  of  tentleraess  on  pressure,  indicating 
localized  jxTitonitis.  In  a  majority  of  cases  we  may  palpate  the 
nonnal  kiibieys,  more  easily  if  they  aiT  enlarged  or  displaced.  We 
palpate  the  eilge  of  the  normal  or  enlarged  liver,  and  a  displaced 
liver,  as  in  entcroptosis,  also  a  distended  gall  bladder,  or  an  en- 
larged spleen,  A  loop  of  bowel  distended  with  feces  and  also  the 
distended  urinary  bla<lder  may  \ye  made  out  by  palpation. 

Suppose*  a  tumor  is  presc^nt;  first  we  di^crmine  its  situation 
by  making  gentle,  firm  pressure  with  both  hautls,  noting  in  wliieh 
cfuadrant  or  cfuadrants  of  the  abdomen  it  is  situate<l  The  ab- 
dominal walls  should  move  with  the  hands  over  the  untlerlying 
Of^ga&s  or  the  tumon  Tumors  situatetl  in  the  struct m-es  of  the 
alxlominai  wall  move  with  the  wall  on  inspiration  and  expiration 
over  the  organs  underneath.  Tumors  of  the  abdominal  and  pelvic 
organs  that  are  adherent  to  the  abdominal  parietes  limit  the 
motion  of  the  walls  on  respiration.  Exceptionally,  in  cases  wliere 
the  walls  are  lax  and  the  tumor  is  not  excessively  large,  tht^  |>hy8ician 
m  able  to  pick  up  the  alxlominai  wall  and  determine  if  it  is  adherent 
to  the  tumor  beneath.  All  the  alxlominai  organs  normally  move 
more  or  less  during  respiration, — ^those  organs  nearer  the  iliaphragm, 
na  the  liver  and  kithieys,  moving  the  most,  while  those  in  the 

'  bottom  of  tlie  abdomen  are  less  affected.  The  size  of  the  tumors 
can  be  learned  only  approximately.     It  is  to  be  borne  in  mind  that 

I  MCBe  tumors  var>'  m  size  at  different  times:  for  instance,  an 
crvarian  cyst  is  smaller  after  there  has  lH>en  free  catharsis  from  the 
bowels,  and  a  fibroid  tumor  of  the  uterus  is  larger  just  befoi-e  the 
eatanienia  and  smaller  just  after. 

The  8bape  of  the  tumor  is  made  out  by  palpating  it  in  several 


70  PHYSICAL  EXAMINATION 

directions.     To  this  end  the  examiner  shifts  his  position  to  the 
left  side  or  to  the  foot  of  the  examining  table. 

The  mobility  of  the  tumor  is  ascertained  by  grasping  it  between 
the  two  hands  and  moving  it  about.  Changing  the  patient's 
position  to  the  lateral  position  may  cause  the  tumor  to  fall  by 
gravity  to  the  dependent  side.  Ovarian  tumors  tend  to  gravitate 
into  the  abdominal  ca\ity  if  the  patient  is  put  in  the  knee-chest 
position.  The  excursions  of  a  movable  tumor  show  us  something 
as  regards  adhesions  and  the  point  of  attachment  and  length  of 
the  pedicle.  Traction  on  the  jxxliclc  generally  causes  pain  re- 
ferred to  the  situation  of  the  pedicle. 

The  consistency  of  a  tumor  is  often  a  difficult  matter  to  pass  on. 
Waves  of  fluctuation  are  made  out  by  a  combination  of  palpation 
and  percussion.  The  hand  of  an  assistant  is  placed,  ulnar  edge 
down,  in  the  longitudinal  axis  of  the  alxlomen  and  firm  pressure  is 
made.  This  is  to  eliminate  the  wave  which  may  be  transmitted  by 
the  fat  of  the  abdominal  wall.  The  physician  taps  one  side  of  the 
abdomen  and  notes  with  the  other  hand,  placed  on  the  opposite 
side,  oscillations  which  may  be  transmitted  through  the  fluid. 
If  a  cyst  is  filled  so  that  the  fluid  is  under  great  pressure  and  if 
the  cyst  walls  arc  thick,  the  fluid  waves  may  be  indistinguishable. 
So  also,  if  the  fluid  is  of  a  thick  consistency,  fluctuation  may  be 
absent. 

Peristaltic  contractions  of  a  piece  of  intestine  are  sometimes 
to  be  distinguished  and  also  the  rhythmical  contractions  of  a 
pregnant  uterus.  To  determine  either  of  these  it  is  necessary  to 
let  the  hand  rest  gently  on  the  abdomen  for  a  considerable  length  of 
time. 

The  point  of  attachment  of  a  tumor  may  be  learned  by  moving 
the  tumor  while  the  hand  is  held  on  a  neighboring  organ  and  noting 
whetluT  the  organ  moves  too,  or  by  movmg  the  organ  and  noting 
the  behavior  of  the  tumor. 

Palpation  of  the  Kidneys. — Palpation  of  the  kidneys  is  best  done 
with  the  patient  in  the  dorsal  position.  The  physician  stands  at 
the  patient's  side  facing  toward  her  head,  his  left  hand  is  placed 
under  the  flank  and  his  right  hand  over  the  flank,  while  the  patient 
takes  a  dwp  breath.  This  process  is  repeated,  the  hands  coming 
together  a  little  more  with  each  expiration.  Time,  gentleness,  and 
gradual  movements  are  important  factors  in  this  manipulation. 


PERCUSSION  OF  THP:  ABDOMEN 


n 


ITie  rij^ht  kidney,  being  a  little  lower  than  the  left,  is  more  accei^iblc 
to  palpation.  With  pmctiee  it  will  l>e  found  that  tliero  are  com- 
paratively few  cfLsn's^ — anil  these  patients  having  very  stout  and 
rigid-walled  abtioniens, — in  which  the  lower  poles,  at  least,  of  the 

'kidneys  can  not  Ix*  felt. 

In  the  case  of  movable  kichiey,  generally  the  en  tin*  kiilney  (*an 
be  outlinefl,  espeeially  where  it  is  enlargeih  Pressure  on  a  tuber- 
culous or  hydronephrotic  kiilney  will  frequently  force  turbid 
urine  through  the  ureter  into  the  bladder.  If  the  bladder  has 
lx*en  emptitni  by  catheter  previous  to  the  examination  and  clear 
urine  obtain<xI,  suoli  a  tirwedure  assists  niaterinlly  in  establishing 
the  diagnosis,  for  a  second  catheterizatio!i  following  paliiatioji 
draws  off  cloudy  urine. 

To  determine  the  extent  of  the  downwanl  excursion  of  a  mis- 
winced  kidney  the  flank  is  palpatetl  eitlier  in  the  sitting  or  in  the 
iding  jxxsition.  In  the  sitting  position  the  patient  sits  on  the 
foot  of  the  table  with  her  feet  in  a  chair,  and  lx»nds  for%vard  slight  ly. 
In  the  standing  position  she  stands  fa<'ing  the  table  and  about  a 
foot  from  it.  Placing  lx)th  hands  on  the  taiiie  she  leans  forward 
so  that  imrt  of  her  weight  is  taken  on  the  handsj  thus  the  ablom- 
inal  muscles  are  relaxed.  This  nianif>ulation  can  Ix*  executed 
bf«t  with  the  asvsistance  of  a  nurse  or  another  woman,  because  the 

'patient  can  not  hold  up  her  locjsened  clothing  and  tx-ar  [>art  of  the 
weight  on  her  hands  at  the  same  time.  Personally,  I  have  Itemed 
to  place  the  chief  reliance  on  the  ilorsal  position  for  |mlf>ation  of 
the  kidneys,  except  to  make  out  the  amount  of  extreme  downward 
6XcurHion»  when  sometimes  the  standing,  and  at  others  the  sitting, 
{xte^qtion  gives  the  better  result, 

8.  Percussion,  Auscultatio.v,  and  Mensuration  of  tuk 

Abdomen 


Tlie  combination  of  pafpation  and  |)ercussion  for  the  dettTtion 
kof  fluid  wav(*s  in  the  abdouien  has  been  described  in  the  discussion 
of  palpation. 

Peixussion  is  Ix'st  practiced  with  the  patient  in  the  dorsal  position. 
By  it  wr  detemiine  the  situation  of  tlie  hiwer  margin  of  tlie  liver- 
duUnes^f  the  area  of  stomach  and  colon  tympany,  splenic  tiullness, 
tbf  dullness  due  to  fecal  accumulations  in  the  bowels  or  urine  in 


72  PHYSICAL  EXAMINATION 

tlie  bladder,  and  the  dullness  caused  by  free  fluid  in  the  peritoneal 
cavity  or  by  the  fluid  or  solid  constituents  of  a  tumor. 

Unfortunately  we  have  no  standard  of  comparison  in  percussion. 
We  can  not  compare  the  percussion  note  of  one  side  of  the  abdomen 
with  that  of  the  other,  and  the  conditions  are  constantly  varying, 
due  to  changeable  quantities  of  fluid,  solid  and  gaseous  matters 
in  the  stomach  and  bowels,  and  the  encroachment  of  one  organ  on 
another.  Also,  there  are  to  be  considered  the  variations  caused 
by  the  normal  mobility  of  the  abdominal  organs. 

Neverthele^,  percussion  is  a  valuable  adjunct  to  palpation. 
Its  chief  use  in  gynecological  diagnosis  is  in  differentiating  between 
ascites  and  a  cystic  ovarian  tumor.  In  the  case  of  ascites,  the  flanks, 
being  the  dependent  portion  of  the  abdominal  cavity  and  there- 
fore occupied  by  fluid,  are  dull  to  percussion.  The  intestines, 
filled  more  or  less  by  gas,  float  on  top  of  the  fluid,  and  give  an  area 
of  resonance  in  the  umbilical  region.  Shifting  the  position  of  the 
patient  to  one  side  sends  the  fluid  (unless  by  chance  it  is  walled 
off  by  adhesions)  to  the  dependent  side,  and  the  resonance  is  to  be 
found  on  the  upper  side  and  flatness  below.  In  rare  cases,  when 
the  ascitic  fluid  greatly  distends  the  abdomen,  there  may  be  no 
change  in  the  area  of  dullness  on  shifting  the  position  of  the  patient. 

In  the  ease  of  a  large  ovarian  cyst,  the  resonance  is  in  the  epi- 
gastric region,  the  intestines  having  been  forced  there  by  the  tumor 
and  the  dullness  is  over  the  an^a  occupied  by  the  tumor.  Change 
of  posture  does  not  alter  the  areas  of  dullness  and  resonance.  (S(k^ 
Figures  132  and  133.)  If  the  gut  has  a  short  mesentery,  the 
intestinal  resonance  may  be  in  the  upper  parts  of  the  flanks,  or, 
in  case  the  intestine  is  occupied  by  fluid  or  solid  fecal  matter,  there 
may  be  little  or  no  resonance,  the  entire  abdomen  being  dull  or 
flat  to  percussion.  A  large  deposit  of  fat  in  the  omentum  may 
cause  dullness  in  any  situation. 

In  gastroptosis  one  detects  the  displaced  stomach  by  inflating  it 
with  gas  by  giving  the  patient  a  dram  of  bicarbonate  of  soda  in 
half  a  glass  of  water,  followed  by  half  a  dram  of  tartaric  acid  in 
another  half-glass  of  water.  Percussion  is  performed  with  the 
patient  in  the  dorsal  position  and  also  in  the  standing  position. 
The  lower  margin  of  the  liver  is  percussed  in  these  two  positions 
and  the  differences  of  level  noted. 

Ausctiltation  is  of  value  chiefly  in  diagnosing  pregnancy.    The 


AUSriTLTATfOiV  f>F  THK  ABDOMEN 


73 


df*t4xrtiori  of  thv  fctnl  lirarWouuiLs,  witli  a  ratr*  riitirf  y  <li(Tomit 
from  that  of  tJie  iiiatrnial  puls<%  is  one  of  tho  al>8oliit(^ly  (llstiiieiive 
signs  of  pregnancy.  Th<*y  ai'e  seldom  tlisternible  Ix^fore  the  twen- 
tieth week,  althoyiih  eiTlain  obMTvers  report  liaviri^  heard  tht*ni 
a^  early  a.^  th*^  twelfth  w<*t'k.  After  tlie  tweiity-t'ii^litli  week  they 
should  almost  alw^ays  be  heard,  if  ^h<*  cliild  is  alive,  at  any  rate 
after  rqM'ated  examinations,  Hyth-nnuiios  or  tliit^k  alxlorninal 
walls  may  prevent  th(»  sounds  from  \wmg  transmitted  to  tlie  ear. 
Tlie  soumls  are  usually  heard  over  tlie  child's  back.  Therefon*, 
mnce  left  positions  of  the  oeciput  arc  the  most  common,  the  hearts 
.*^>tmt!s  are  ^enei-ally  to  Ix^  heard  on  a  line  drawn  from  the  uni- 
biUcus  to  the  left  anterior  superior  spine  of  the  ilium. 

If  they  are  not  heanl  in  this  n«gion  the  entire  abdomen  should 
be  auseultated  carefully.  Changes  in  the  pa^ition  of  the  child  may 
make  the  sounds  audible  at  one  time  niul  inamlible  at  another,  so 
that,  should  there  Ix'  a  failure  to  hear  them,  more  than  one  exam- 
ination is  to  be  made.  Occasionally  the  child's  position  may  h^ 
changed  by  manipulation  for  [)ur[ios4*s  of  auseultation,  so  tliat  it-8 
Ijftek  comes  against  ttie  alxbnjinal  j>arietes  of  the  mother.  Some 
ph\-sieians  prefer  diixrt  auscultation,  with  the  ear  applied  to  the 
alj<lomen,  to  the  mediate  auscultation  of  the  Btethos<;*ope, 

The  binaural  stethoscope  is  the  best  means  for  detecting  the 
fetal  heart -sou  nils.  Its  mouth  should  Im  moistened  to  do  away 
with  the  noise  generated  by  the  slip[ung  of  the  stetlioseope  on  tht^ 
tin.  Generally  the  lightest  ]>ossiIile  pressure  of  the  stethoscofie 
the  skin  is  advisable,  and  to  this  end  it  is  lx\st  to  let  it  rest  by 
itoown  weight  and  not  to  hokl  it  with  the  fingei-s.  The  lx*ating  i»f 
the  fetal  heart  (130  to  140  beats  a  minute)  has  l)een  likened  to  the 
ticking  of  a  watch  under  a  pillow.  To  make  the  rliagnasis  sun:*, 
the  rate  shouki  be  counted  for  a  minute,  and  thus  it  is  <lilTrrentiatrd 
from  the  maternal   pidse,  which  is  counted  by  the  physician's 

iger  on  the  mother*s  radial  artery. 

Tlie  uterine  souffle,  or  bruit  so  called,  is  an  intermittent  blowing 
gound  sjTichronous  with  the  patient's  pul^^e.  It  oecurs  not  only 
in  pregnancy  but  also  in  fibroids  of  the  uterus  and  in  other  uterine 
and  even  ovarian  tumors,  and  is  probably  due  to  incn7ise<l  circula- 
tion in  enlargeil  blood-vessels.  It  is  of  no  special  diagnostic  im- 
|»ortance.  The  noist«  made  by  gas  in  the  stomach  and  mtestines 
arc  to  be  detected  bv  auscultation. 


J 


74  PHYSICAL  EXAMINATION 

In  cases  of  peritonitis,  one  may  determine  by  tliis  means  whether 
the  {xjristaltic  movements  of  the  intestines  are  still  present.  Fric- 
tion sounds  made  by  the  rubbing  together  of  roughened  surfaces 
of  tumors  and  adjacent  structures  may  sometimes  be  heard,  also 
the  murmur  transmitted  from  an  abdominal  aneurysm. 

Mensuration  is  a  means  of  determining  the  rate  of  growth  of 
an  abdominal  tumor.  Exact  measurements  are  impracticable 
because  of  the  varying  state  of  the  bowels  as  to  distention  or 
relaxation,  and  also  because  of  the  yielding  nature  of  the  tissues 
and  the  mobility  of  the  tumors.  Nevertheless,  much  may  be 
learned,  in  cases  of  chronic  enlargement  of  the  abdomen,  by  making 
careful  measurements  at  repeated  examinations  several  weeks  or 
months  apart.  These  are  made  partly  with  a  tape  measure  and 
partly  with  a  pelvimeter,  and,  for  purposes  of  comparison,  all 
subsequent  measurements  should  be  made  imder  as  nearly  similar 
conditions  as  to  time  of  day,  time  after  menstruation,  state  of  the 
bowels,  etc.,  as  possible.  They  should  always  be  made  with  the 
patient  in  the  same  position  and  with  all  clothing  loosened.  Very 
light  contact  pressure  with  the  tape  or  pelvimeter  on  the  skin  is  best. 

The  measurements  to  be  taken  are: — the  greatest  circumference; 
the  circumference  at  the  umbilicus;  the  distance  from  the  cnsiform 
cartilage  to  the  symphysis  pubis;  from  the  umbilicus  to  the  an- 
terior superior  spine  of  the  ilium  on  each  side;  and  the  greatest 
diameter  of  the  abdomen  as  measured  with  the  pelvimeter,  the 
patient  standing,  one  point  of  the  pelvimeter  being  placed  over 
the  most  prominent  portion  of  the  abdomen,  and  the  other  over 
the  spinous  process  of  some  definite  counted  sacral  vertebra. 

Dr.  Howard  A.  Kelly  (^^  Medical  GjTiecologj^"  p.  17)  has  devised 
a  method  for  making  permanent  gauze  records  of  abdominal 
tumors  and  displaced  viscera.  The  patient  being  in  the  dorsal 
position,  the  physician  outlines  the  tumor  and  the  landmarks, 
such  as  anterior  superior  spines  of  the  ilia,  margins  of  the  ribs, 
symphysis,  and  umbilicus,  on  the  skin  of  the  abdomen  with  an 
aniline  i>encil.  If  the  skin  does  not  take  the  pencil  marks  well, 
wet  it  with  a  little  alcohol.  Lay  a  plate  of  glass  over  the  abdomen 
and  on  it  place  a  piece  of  stiffened  gauze  (suisse,  nainsook,  or  organ- 
die). The  skin  markings  are  visible  through  the  glass.  Reproduce 
them  with  a  crayon  pencil  on  the  gauze.  File  away  the  gauze, 
labeled  with  the  patient's  name  an(l  the  date,  for  future  reference. 


76  PHYSICAL  EXAMINATION 

The  X-rays  in  Diagnosis. — The  X-rays  are  of  supplementary 
diagnostic  value  in  detecting  stone  in  the  ureter  or  kidney,  and  in 
determining  ptosis  of  the  stomach  and  intestines  when  these  organs 
are  filled  with  bismuth  in  suspension,  also  the  presence  of  bone  in 
tumors, — conditions  important  for  the  g}Tiecologist  to  recognize. 
One  skilled  in  the  use  of  the  Roentgen  rays  shouki  be  caUed  in,  as 
the  neophyte  is  apt  to  be  mislwi  by  the  appearances  s^^en  in  the 
photographic  platee,  and  to  put  a  wrong  interpretation  on  their 
showings. 


CHAPTER  \'II 
THE   PHYSICAL    EXAMINATION   {Conclvded) 

III.  The  examination  (ronriuded):  9.  InstnimenL'^  ami  Iheir  use  in 
duignosts,  p.  77:  General  remiirkii.  p  77,  The  uterine  sonml,  ji.  78:  When 
to  pmm  it,  p.  78;  Methods  of  passing;,  p.  7J^;  Faets  lu  l»e  detenninetl  by  the 
u«e  of  the  sound,  p.  80;  Cantioris,  ji.  84,  The  uterine  protxs  p,  84.  Tlic 
uU-rine  dressing  forceps,  p.  83.  The  uteri iie  teiiaenhini,  p.  8L  The 
vulscllum,  or  double  tenacnhini  forcej^s.  p.  8i.  The  vapinal  s(M?eul*iin.  p, 
85:  The  bivalve »  or  duc-khili  i^jeeuluni,  p.  S3:  The  Xen^*hauer  bivalve 
9(M*cu)um,  the  Ferj^uson  s[M*cuiunijhe  Simon  s[it*enlum,  and  the  Eflebf»hb 
speculum,  p,  86;  The  Sims  sfM'eulura,  p.  87.  The  Hunter  depressor,  p. 
88,  The  Emmet  curette  foreejjs,  p.  89,  The  ulerine  curette,  p.  !10. 
Curetting,  p.  90:  Dangers  of  cure! ling,  p.  93.  Digital  explfjratiou  of  the 
ut4?'rinc  cavity,  p.  IH,  Pelvimetry^  p.  95:  Externa!  or  BaudeKKnue  s 
eoiijugate  diameter,  p.  Uil;  The  obli*jttc  con  jugate  diameter.  |>.  97;  The 
trnnsversc  diameter,  p.  98:  The  tninsverse  difinicter  of  the  outlet,  p,  98. 
The  capacity  of  the  pelvic  cavity,  p>  98;  The  obhijue  diagonal  diameters, 
p.  08. 

THE  EXAMINATION   (Concluded) 
9.  Instruments  and  their  Use  in  Diagncjsis 

In  a  fiiajority  of  g\Tit'c<>hjgif'al  <lispases  the  diagnosis  h  tnadc* 
wilhout  thr  use  of  instrunicuts.  They  are  not  the  most  iinijortarit 
part  of  the  physieian\s  equipimmt.  No  matter  how  ingeiiiousty 
con^tructeil,  and  be  they  ever  so  well  adapted  to  their  U8(»8,  instru- 
ments in  the.se  days  ean  not  take  the  place  of  the  (xlueated  toueh. 
The  physieian,  jiartieularly  t!ie  American  physician,  with  his  native 
mechanical  bent,  aJthouKh  nundful  of  the  rt*vo]utionizing  of 
gynct'ology  by  the  sjieculuin  (which  his  coiuitryrnan,  J.  Nhirion 
tilmSy  K^ve  to  the  world)^  should  forswt^ar  the  wiles  *»f  the  ijistru- 
HMnjt'iuaker  anil  devote  liis  attentiou  to  training  his  touch,  leaving 
tn;^mfnent8  to  the  last. 

Tlie  imnietliate  followers  of  Sims  and  Eiiimi't  W(»re  so  p1eas<^d 
irilh  the  newly  disi-overtMl  vaginal  sptrulum  and  with  titoir  al»ility 
to  ini^pect  the  va^a  by  it8  skillfid  u^se,  that  they  were  quite  eoiitt^nt 

77 


78  PHYSICAL  EXAMINATION 

to  rest  their  diagnoses  of  uterine  disease  on  what  they  saw  through 
the  speculum.  Hence  it  followed  that  for  the  time  other  means  of 
investigation  were  slighted  and  only  in  recent  years  has  the  pro- 
fession escaped  from  the  thrall  of  the  speculum. 

Out  of  a  number  of  instruments  each  examiner  and  operator 
will  have  his  personal  preference  for  those  which  seem  best  to 
serve  his  needs.  My  full  kit  of  instruments  is  to  be  found  in 
Chapter  IV.,  page  28. 

The  Uterine  Sound. — The  uterine  soimd,  although  employed  less 
and  less  as  skill  in  the  bimanual  touch  increases,  is  on  the  whole 
the  most  valuable  of  the  instruments  used  in  diag- 
^^        nosis.     In  the  days  of  Peaslee,  Simpson,  and  Sims, 
^  the  use  of  the  sound  was  much  abused,  as  the  other 

means  of  diagnosis  had  not  been  perfected  at  that 
time.  The  student  was  taught  to  pass  the  sound  in 
nearly  all  cases  of  uterine  disease,  and,  as  aseptic 
methods  were  unknown,  the  results  to  the  patient 
were  too  often  disastrous.  Not  only  was  the  sound 
passed  into  the  uterine  cavity,  but  malpositions  of 
the  uterus  were  forcibly  corrected  by  this  means,  thus 
adding  trauma  to  infection.  At  the  present  time  the 
sound  is  employed  to  confirm  a  diagnosis  made  by  the 
bimanual  touch,  and  in  certain  rare  conditions  to  make 
a  diagnosis  where  the  touch  can  not  be  used. 

The  sound  is  to  be  preferred  to  the  probe  because 
the  slightly  larger  end  of  the  sound  will  slip  over 
The  Uterine  irregularities  in  the  mucous  membrane  lining  the  cavi- 
Sound.  ties  of  the  cervix  and  the  body  of  the  uterus,  while 

the  tip  of  a  probe?  will  catch  in  them.  A  sound  of 
small  caliber  made  of  flexible  copper,  with  a  knob  at  the  distal  end, 
one  side  of  the  handle  Ixnng  rough  and  the  other  smooth,  should  be 
chosen.  One  side  of  the  handle  is  made  rough  so  that  the  operator 
may  be  informed  as  to  the  direction  taken  by  the  point  of  the  bent 
instrument  when  sounding  a  deep  and  tortuous  uterine  cavity  or 
sinus.  The?  sound  may  be  graduated  in  inches  or  centimeters, 
according  to  the  pref(M-ence  of  the  physician.  It  is  easier  to  keep 
it  ch^an  if  it  has  no  not(»h(\s.  The  measurements  are  taken  by  mark- 
ing th(^  depth  to  which  it  has  entered  the  uterus,  by  means  of  the 
finger  tip  held  against  the  sound,  or  the  dressing  forceps  grasping 


INSTRUMENTS  AND  THEIR  USE 


70 


the  sound  at  the  external  Of^  ami  tlien,  on  withdrawing  it,  compar- 
ing the  measurenients  with  a  meavSurcMl  si^ale  on  ihv  inhh'  on  wliich 
tlie  instruments  are  placet L 

Before  pasi?ing  the  soiuid  the  vagina  niu.si  be  eleanstnl  in  vvcry 

a^so.  We  do  not  know  \\1mt  baeterial  gro^ih  may  h*  j)restjnt  in 
the  vagina.  As^umin^  that  there  an*  no  pathnt/f^nic  nr;ranisms 
|>re*^:Tit  under  norninl  eonditions,  some  are  intruilyeed  from  the 
external  gt^nitals  in  the  course  of  the  vaginal  touch,  which  always 
preccnles  the  me  of  the  sound.  To  idranse  the  vagina,  swab  it  out 
several  times  with  pledgets  of  absorlirni  cotton  hcltt  in  th**  uterine 
clrcs?isting  forceps  arnl  dii)i)e<l  in  a  warm  solution  of  creolin  and 
water  (one  per  cent). 

The  soimd  may  bt*  passed  (1)  bimanualJy^  the  patient  being  in 
the  dorsal  position.  To  do  this  the  |>h>^*^ician  seizes  a  piece  of 
abeorlx^nt  cotton  in  the  uterine  dressing  forceps  held  in  his  right 
hand,  and  carries  it  througli  the  warm  creolin  solution;  now  dc- 
preasmg  the  patient's  [jcrineuin  with  his  left  fort^fiiiger  hi  the 
VBgtna,  he  swabs  out  the  entire  vagina,  repeating  tlie  process 
several  times.  Ikying  tlown  the  tiressing  forceps  hv,  takes  up  the 
sound.  The  situation  of  the  external  os  is  determined  with  the 
tip  of  the  left  forefinger,  and  the  knol>like  end  of  the  sound  is 
CArriecI  along  the  left  forefinger  until  it  enters  the  os.  The  furtlier 
nmuipulations  are  directeil  by  the  niformation  as  to  location,  axis 

id  sliajK?  of  the  uterus,  gainwl  by  tin*  bimanual  touch.  It  Is 
3mary  to  bend  sliglitly  tlie  distal  two  inches  of  tlie  soimd 
the  roughened  side  of  its  handle.  The  sounti  is  held  lightly 
fat  the  right  hand  ami  allowe<l  to  slide  in  by  its  own  weight.  For- 
eihle  raovement-s  are  al>snlytely  contraindicated  and  unnecessary. 
Tlic*  physician  w^ho  uses  fcjrce  then^by  di^monstrates  tliat  he  lias 
failed  in  liis  bimanual  touch.     If  the  sounii  does  not  pass  readily 

i^hould  he  withdrawn  and  tlie  end  fx-nt  at  a  different  angle  and 
pjntroduceth  RemembtT  that  tht*  barriers  to  the  intrmluetion 
of  the  ^und  are  at  the  external  and  internal  ora.  The  internal  os 
is  always  closed  except  w4ien  blocxl  is  passing  out  of  the  uterine 
cavity,  after  labor,  or  in  certain  i»athological  states. 

In  some  cases  where  tht^  uterus  is  sharply  flexinl,  and  when  it  is 

;h  in  the  pelvis,  the  cervix  may  \)Q  gnisixd  with  a  tenaculum 
and  ilrawn  toward  the  \iilva  to  facilitate  the  intrtxluction  of  the 
aoimd.     The  tenaculum  should  be  a  single  one,  mtroducctl  into  tlie 


80  PHYSICAL  EXAMINATION 

cervical  canal,  not  a  double  tenaculum,  which  makes  two  holes  in 
the  cervix  and  may  start  a  hemorrhage  and  cause  pain. 

The  sound  may  be  passed  (2)  by  sight.  For  this  purpose  the 
patient  is  in  the  dorsal,  the  Sims,  or  the  knee-chest  position.  If 
in  the  dorsal  position  the  bivalve  speculum  is  introduced  and  the 
vagina  cleansed.  The  cervix  is  steadied  with  the  tenaculum  and 
the  sound  mserted  in  the  uterine  cavity.  If  in  the  Sims  position 
the  Sims  speculum  is  introduced,  and  the  manipulations  are  as 
in  the  dorsal  position.  If  in  the  knee-chest  position,  the  Sims 
speculum  is  introduced  and  the  vagina  balloons  with  air,  the  uterus 
falling  forward  toward  the  abdomen.  In  this  position  it  will  be 
found  necessary  generally  to  seize  the  cei-vix  with  a  tenaculum  and 
raise  it  before  the  sound  will  enter. 

The  uterine  sound  shows  the  depth  and  direction  of  the  uterine 
canal,  the  size  of  the  external  and  internal  ora,  the  shape  of  the 
uterine  cavity,  situation  of  lacerations  of  the  cervix,  irregularities 
of  the  mucosa,  the  situation  of  the  pedicle  of  a  uterine  polyp  or 
submucous  fibroid,  the  tonicity  of  the  uterine  walls,  and,  by  biman- 
ual touch  with  the  sound  in  the  uterus  and  the  hand  on  the 
abdomen,  the  thickness  of  the  uterine  walls. 

In  passing  the  sound  one  measures  thc^  distance  from  the  ex- 
ternal OS  to  the  internal  os  where  the  tip  of  the  sound  catches,  and 
thus  estimates  the  length  of  the  cervical  canal.  The  remaining 
distance  from  the  internal  os  to  the  fundus  gives  the  depth  of  the 
uterine  cavity  proper.  In  this  way  are  distinguished  the  uterus 
of  the  little  girl,  the  so-called  infantile  uterus  with  its  long  cervix 
and  short  body,  and  hypertrophic  elongation  of  the  cervix,  an 
exaggeration  of  the  infantile  uterus;  the  atrophic  uterus  of  old  age 
with  small  body  and  shortened  cervix;  lactation  atrophy,  and  the 
uterus  deprived  of  its  cervix  by  amputation. 

The  uterine  cavity,  as  a  whole,  is  increased  in  size  in  pregnancy, 
subinvolution,  hypertrophic  elongation  of  the  cervix,  and  new 
growths.  It  is  diminished  in  atrophic  conditions, — either  failure 
of  development  or  acquired  atrophy, — ^in  inversion,  and  in  new  for- 
mations encroaching  on  the  cavity. 

In  investigating  the  direction  of  the  uterine  canal  it  must  be 
borne  in  mind  that  th(»  cervical  canal  may  extend  in  one  direction 
while  th(»  uterin(»  cavity  is  at  >an  angle  to  it,  as  in  ant(»flexion  and 
retroflexion.     Inflammatory  exudate  or  new  growths  in  the  neigh- 


INSTRUMENTS  AND  THEIR  USE 


81 


J>orhood  of  the  uterus^  by  causing  tlisplacemeiit,  may  alter  tlie 
(lirection  of  the  canal. 

Stenosis  of  the  externul  crs  is  (•onimon  in  certain  forms  of  anti^ 
flexion  where  we  find  the  isoealleil  *Vpinhole  os,"  in  senile  atrophy, 
and  following  imj:»ro|wrly  performed  o[>eration«  on  the  cer\1x. 
Fal^  stenasis  of  the  internal  os  h  apparent  in  many  cases  of 
anteflexion,  the  sound  passing  when  the  utenis  has  l>een  straight- 
ened by  traction  on  the  CiTvix  with  a  tenacuhim.  True  stenosis 
Ls  found  after  injuries  of  the  internal  os  due  to  too  vigorous  curetting 
or  to  steaming;  from  inHannnation  in  the  tissues  in  this  neighbor- 
hood, as  in  cases  of  cancer  of  tlie  cervical  canal  (adenocareinoma}; 
in  senile  atrophy;  and  it  may  fx*  congenital,  as  in  hematornetra. 

Both  the  intenial  os  and  the  external  os  may  Ije  eidarged  in 
snibin volution  and  as  a  result  of  laceration. 

It  is  important  to  deteiTuimt  whether  the  internal  os  also  is 
lacerated  in  cases  where  there  arv  lacerations  in  the  external  os. 

\hi  IB  done  by  the  sense  of  toucli  comnumicatetl  througli  tlur 
nKJund,  The  situation  and  extent  of  laceration  are  determined 
partly  by  recognizing  the  landmarks  in  the  mucosa  of  the  cervical 
canal  in  the  form  of  the  arbor  vita^  and  by  trjing  to  reconstruct 
the  cervix  in  its  original  form  by  rolling  the  evert et!  niges  togethrr 
with  tenacula,  also  by  |>Iacing  the  sound  over  th<'  arbor  vita^  with 
il«  tip  at  the  middle  of  the  fim<lus  ami  noting  whether  a  lacemtion 
is  on  one  or  both  sides  of  the  sound,  (Scv  Chapter  X III. ,  p.  21)9.) 
The  m>imd  gives  a  gcKxI  idea  of  the  shape  and  size  lx>th  of  the 
cer\'ical  canal  and  of  the  uterine  cavity  i)roper. 

The  physician  while  passing  the  somid  should  keep  in  mind 
ahraj's  the  shape  of  the  normal  uterine  cavity  (see  Figures  64,  67, 
ami  68,  pp.  166,  171,  172),  an  isosceles  triangle,  having  as  IxiuiifU 
aries  front  wall,  back  wall,  fundus,  and  internal  os.  There  art* 
no  mde  walls,  but  in  their  place  are  the  two  fuiTOws  forme<l  by  the 
meeting  of  the  front  and  bark  walls,  beginning  below  at  the  internal 
ixi  and  ending  above  m  the  uriHce.s  u{  the  Fallopian  tulx's. 

The  internal  os  being  relaxed  or  dilatcnl,  the  proi>erIy  bent  sound 
b  peAm:Hl  lightly  and  methodically  over  ante:*rior  wall,  posterior 
wall,  fundus,  and  lateral  furrows,  dt^tecting  fimgosities  or  inequal- 
iiies*  in  the  mucosa,  or  a  fH^dimeulateil  growih.  The  last  is  very 
(Itifieult  to  do,  and  is  not  possible  in  all  cases.  It  is  surprising, 
however,  how  much  may  be  learnts!  by  tmining  the  sound-touch. 


82  PHYSICAL  EXAMINATION 

By  sound-touch  the  firm,  elastic  resistance  of  the  healthy  uterus 
may  be  differentiated  from  the  sclerosed  tissues  of  subinvolution 
or  the  soft  tissues  of  the  septic  uterus. 

With  the  sound  in  the  uterus  and  the  fingers  on  the  abdomen  or 
with  a  finger  in  the  rectum,  it  is  possible  sometimes  to  estimate  the 
thickness  of  the  uterine  walls. 

Cautions. — The  greatest  caution  is  to  be  exercised  in  passing 
the  soimd  in  infcjctious  cases,  especially  in  gonorrhea,  because  the 
sound  will  carry  the  infective  bacteria  beyond  the 
natural  barriers  at  the  external  and  internal  ora.    Also 
in  cases  of  septicemia  and  advanced  cancer,  the  sound 
should  be  used  with  circumspection  because  of  the 
danger  of  perforation  which  is  most  ea^^ily  made  under 
these  conditions,  the  uterine  structure  often  being  so 
soft  as  to  offer  practically  no  resistance  to  the  pass- 
age of  the  soimd  through  it.     Perforation  occurs  oc- 
casionally under  such  conditions  in  the  hands  of  the 
most  careful.     Never  pass  the  sound  into  the  uterine 
cavity  without  fii^st  asking  the  patient  the  date  of  her 
la^t  menstruation.     Make  this  an  invariable  rule,  and, 
not  forgetting  the  possibility  of  prevarication,  and 
also  having  fresh  in  mind  the  result  of  the  bimanual 
examination, — the  invariable  preciu^or  of  the  use  of 
any  instrument, — you  will  avoid  making  that  most 
serious  of  all  gynecological  mistakes,  the  sounding  of 
the  pregnant  uterus. 
Fig.  22.—         The  misplaced   uterus  should  never  be  replaced 
p  ^,     ^""^     with  the  sound,  a  practice  much  in  v6gue  twenty 
years  ago.     If  the  uterus  is  freely  movable,  not  held 
by  adhesions,  it  can  always  be  replaced  by  bimanual  manipulation 
together  with  traction  by  a  tenaculum  in  the  cervix,  making  use 
of  one  or  more  of  the  various  gynecological  positions.    One  at- 
tempt should  not  discourage.     More  favorable  conditions  may 
obtahi  at  another  time. 

Besides  its  use  in  the  uterus  the  sound  may  be  used  to  investigate 

the  bladdtT — its  situation,  as  in  prolapse  of   the  uterus  and  in 

tumoi-s;   also  the  situation  of  sensitive  areas  and  the  presence  of 

stone  or  phosphatic  deposits  in  the  bladder. 

The  Uterine  Probe. — The  uterme  probe  has  the  same  uses  as  the 


INSTRUMENTS  AND  THETll  USE 


83 


I 


surgical  probe,  and  b(»sidt*s  having  a  Imndle  and  a  Jong  shaft,  it 
cnn  be  usc^d  to  investigate  the  interior  of  small  uteiine  ranaln,  ainl 
niay  l>e  hmt  to  eonfonn  to  tortuous  uterine 
interior.s  or  long  amuses.  The  probe  supple- 
fnerjtj!«  the  sound,  but  as  an  aid  to  diagnosis 
sshould  not  gfupplant  it. 

The  Uterine  Dressing  Forceps. — My  pref- 
crenee  for  a  thessin^  forct  jis  is  one  niatle 
on  the  seissors  prinripit%  as  this  seems  best 
to  supplement  thu  hand  in  uterine  manipula- 
tions. The  forcep'*^  known  as  Boxenian  s, — ■ 
detaelmbk*  l»lades  with  double  eurve,  catch, 
and  aerrated  jaws,— makes  one  of  the  most 
useful  instmment8  known  to 
gynecological  art.  With  it  we 
not  only  graqi  pledgets  of  cot- 
ton with  ^vlilch  to  wi|x*  away 
I  the  discharges  and  cleanse  the 

vagina,  but  also  remove  a  bit 
of  strmgy,  tenacious  discharge 
from  the  os  uteri,  or  pit'^ci\s  of 
tissue  from  tlie  os  or  vagina  for 
mieroscopie  or  bacteriological 
examination. 

By  grasping  with  the  for- 
ceps the  uterine  sound  while 
in  the  uterus  at  a  point 
where    it     proj(*cts    from    the 

external  os,  the  de(>th  of  the  uterine  cavity  is 
measured  on  a  clean  towel  when  the  sound  is  with- 
drawn. 

The  cur^'cs  in  the  blades  of  the  instrument  permit 
of  it-s  entering  the  uterine  cavity  or  a  sinus  while  tin: 
hand  w^hich  holds  it  does  not  obstruct  the  operator's 
view.  Being  made  on  the  scissors  principle,  levers 
of  the  first  ckss  with  the  fulcrum  some  distance 
fftim  the  jaws,  one  is  4ible  often  to  open  the  jaws  in  a  ca\ity 
(uterine  cavity  or  sinus),  after  passing  through  a  narrow  opening 
(interoa]  oe),  or  skin  entrance, — something  tliat  a  forceps  made 


Fro.    23.  — l^terine 
Dressing  Forceps, 


Fig.  24.— 
Ulerifie  Toil' 
aeulnm. 


84 


PHYSICAL  EXAMINATION 


on  the  principle  of  the  Sims  uterine  dressing  forceps,  levers  of  the 
third  class,  will  not  do. 

In  an  emergency  the  Bozeman  dressing  forceps  may  be  used  as 
a  hemostatic  forceps.  The  jaws  may  be  wound  with  absorbent 
cotton  and  thus  used  to  make  applications  to  the  interior  of  the 
uterus  or  a  sinus,  and  the  forceps  may  be  used  also  to  hold  nitrate- 
of-silver  pencils  for  cauterizing  granulations. 

The  Uterine  Tenaculum. — This  is  to-day  a  neglected  instrument. 
When  used  in  days  gone  by  to  manipulate  silver  wire,  the  tenac- 
ulum was  indispensable.  The  form  of  tenac- 
ulum  devised  by  Emmet  and  Sims  for  shoul- 
dering silver  wire  is  the  best  for  general  use — 
i,e,,  one  with  a  right-angled  end,  instead  of  a 
hook,  for  the  reason  that  it  holds  the  tissues  at 
the  point  where  !t  is  introduced, — is  less  likely 
to  tear  not  only  the  tissues  of  the  patient  but 
the  operator's  finger,  and  it  is  more  readily 
withdrawn  from  the  tissues  when  desired.  It 
should  be  introduced  into  diseased  tissue  when 
possible  and  does  less  damage  and  stays  in 
place  better  in  the  hard  resistant  mucosa  of  the 
cervical  canal  than  in  the  friable  mucous  mem- 
brane covering  the  vaginal  portion  of  the  cer- 
vix. 

Although  the  double  tenaculum  forceps,  or 
vulsellum,  holds  more  firmly  than  the  single 
tenaculum,  the  single  one  makes  but  one  punc- 
ture, causes  less  pain  and  no  hemorrhage,  and 
is  to  be  preferred  in  the  routine  of  examina- 
tions. 

Tenacula  are  of  immense  benefit  in  diag- 
nosis, in  steadying  and  drawing  down  the  cer- 
vix both  for  the  bimanual  examination  and 
for  inspection,  in  rolling  together  the  lips  of  a  torn  cervix  to  estimate* 
the  situation  and  extent  of  the  tears,  to  reconstruct  the  lacerated 
perineum  by  hooking  the  landmarks  and  drawing  them  together, 
and  in  seizing  and  fixing  a  portion  of  cervical  tissue  to  be  removed 
for  the  purpose  of  microscopical  diagnosis.  The  slender  tenaculum 
does  not  bruise  the  tissues  as  does  the  tissue  forceps. 


Fig.  25.— Vulsellum 
Forceps. 


TNSTRirMENTS  AND  THETH  USE 


86 


The  Vulsellum  or  Double  Tenaculum  Forceps*^ In  rlioasing  an 
iiif^trumont  of  this  sort  mw  shoultl  aim  at  having  it  not  too  heavy 
anfl  yi't  with  strel  ctiou^h  to  prevent  the  Wadt^s  sprinw;in^  apart. 
The  8Q-calleil  Aiueriean  bullet  forceps  with  two  points,  and  having 
a  check  on  one  blade  that  prevents  the  blatles  crossing,  is  excellent 
and  most  useful.  Vulsella  ma<le  after  the  principle  of  Museaux^s 
foreeps  (four  points),  or  the  French  hea\T  vulsella  (four  or  more 
points),  are  us4»ful  in  the  luoreellation  of  fibroid  tumors  and  the 
rcrmoval  of  cancer,  but  have  no  place  in  diagnosis.  The  double 
teBaculuni  forceps  is  useful  in  holdin;^  tfie  cervix  duritij^  dilatation 
when  it  is  nccessar>^  to  have  a  firmer  bold  than  the  single  tenaculum 
will  give,  and  in  seizing  ixxiunculated  tumors  in  the  vagina,  al^o 
for  holding  and  drjiwing  down  tlic  uterus  while  practicing  the 
bimanual  touch  to  determine  the  n^lation  of  a  tumor  to  tliis  organ. 
(Sch:  Figure  I2tl) 

The  Vaginal  Speculum. — As  has  }yt\m  said  previoiusly,  most  of  the 

diagnosis  in  uterine  dis(»ast»s  is  rnadt*  by  the  sense  of  touch.     The 

va^nal  s|>eeulum  offers  us  a  view  of  the  vagina  and  vaginal  portion 

I  of  the  cervix.     Of  the  multitude  of  difTen'Ut  forms  of  specula  to 

be  had  of  the  instrument  makers,  the  most  generally  useful  are  the 

,  bivalve   anc'    the   Sims.      The    EdebohU-   specnium    with    winght 

attached  is  for  use  in  curetting  an<l  manipulations  performed  with 

the  patient  anei?thetized.     In  children  a  good  view  of  the  vagiTia 

■  may  be  obtainetl  through  a  Kelly  cystosrope,  using  as  large  a  one 

ns  will  go  through  the  vagina!  introitus  witliout  injuring  the  hymen, 

the  jmtient  bnng  in  the  knce-(*hest  jjosition, 

Tfm  Bivalve  or  DmkbiU  Sf^eeidum. — There  are  many  goo<i  forms 

of  this  speculum  on  tlit'  market.     The  writer  prefers  those  called 

b3*  the  names  of  Brewi^r  and  Graves,  h^-ause  of  their  sirupli<*ity 

^and  usefulness  under  varying  conditions.     Mf>re  than  one  speculum 

[i^hould  bt^  in  every  kit  for  the  reason  tliat  vagime  var>^  so  in  size. 

With  a  girl  having  a  narrow  vagina  and  a  not  easily  dilatable  h\mien, 

a  ifiiiall  s[K*culum  is  calletl  for,  whereas,  for  a  woman  ha\ing  ex- 

Itciwvp  injuric^s  of  the  [ndvic   floor  ami  perineum  and  lax  and 

[ri»flunilant  vaginal  walls,  a  large  sjx'cuhim  is  a  necessity.    The 

f|Milient  is  in  the  dorsal  position.     To  introduce  the  bivalve  speculum 

^be  left  forefinger  is  anointed  with  lubrichondrin  and  both  valves 

of  the  .speculum  are  smeannl  with  it.     The  fon'finger  is  intrmluced 

mXo  the  vagina  a^^  in  making  the  digital  examination,  the  perineum 


86  PHYSICAL  EXAMINATION 

is  depressed,  and  the  speculum  introduced,  the  slit  between  the 
blades  being  vertical.  Before  the  speculum  has  reached  its  deepest 
point  of  entrance  it  is  turned  so  that  the  short  blade  is  above  and 
the  long  blade  behind.  By  means  of  the  lever  connected  with  the 
handle  of  the  speculum  the  blades  are  separated  until  the  cervix 
is  engaged  between  their  ends,  then  they  are  held  in  place  by  the 
set-screw  on  the  handle.  Some  bivalve  specula,  such  as  the  Graves, 
are  provided  with  a  second  set-screw  with  which  to  hold  the  sepa- 
rated bases  of  the  blades,  thus  increasing  the  spread  of  the  specu- 
lum at  the  introitus  vaginae,  and  adding  to  its  usefuhiess  in  cases 
of  roomy  vagina). 

Care  must  be  exercised,  in  handling  the  bivalve  speculum,  not  to 
pinch  folds  of  the  vagina  and  the  labia  minora  between  the  bases 
of  the  blades.  This  is  most  easy  to  do  when  the  vagina  is  lax  and 
the  labia  minora  long.  One  objection  to  the  bivalve  speculum  is 
that  its  blades  cover  both  the  anterior  and  posterior  walls  of  the 
vagina,  thereby  obscuring  them  from  view.  This  defect  may  be 
overcome  in  some  cases  by  turning  the  speculum,  first  having 
loosened  the  lever  holding  the  blades,  so  that  the  blades  are  on 
either  side  of  the  vagina.  The  cervix  is  to  be  brought  into  view, 
if  it  does  not  readily  present,  by  hooking  a  tenaculum  in  the  os  and 
drawing  the  cervix  downward. 

Tlie  Neugebauer  bivalve  speculum  and  the  Ferguson  cylindrical 
speadum  are  used  by  some  gynecologists.  The  latter  covers  the 
entire  vagina  and  is  of  little  value  in  diagnosis.  The  former  re- 
quires much  skill  in  handling  to  prevent  pinching  the  vagina  or 
labia,  and  when  in  place  has  no  advantage  over  the  duckbill  specu- 
lum. 

There  are  various  specula  for  use  with  the  patient  in  the  dorsal 
position  that  depress  the  perineum  and  posterior  wall  without 
covering  the  ant(»rior  wall,  such  as 

The  Simon  specuhim,  which  is  one-half  of  a  Sims  specuhmi. 
These  specula  are  chiefly  usi^ful  in  opiTative  procedures  where  the 
patient  is  ant^sthetized  and  is  not  (tailed  upon  to  endure  the  dis- 
comfort caused  by  prolonged  traction  on  the  perineum.  For 
operative  proc(M lures  the  simplest  and  best  speculum  of  this  class 
is  die  Edebohls  speculum  with  a  solid  flattened  weight  weighmg 
about  a  pound  and  fitted  with  a  hook,  instead  of  the  little 
pail  usually  sold  with  the  speculum.    The  weight  is  made  flat  so 


IN-STRtTMENTS  AND  THEIR  USE 


87 


Fio.  26. — Brewer  Bivalve  Speculum. 


that  it  cl<x*s  not  takr  up  ut^eful  space  at  tlie  inul  of  the  ofM'ratmg 

table,     A  weiglit  may  be  improvisixl  <.*asily  out  of  a  piece  of  leacl 

pifx*  lianimcn»tl  Hat  aiid    per- 

foratetl  to  take  a  hook  made 

out   of    a   piece  of  stout  iron 

wire. 

The  Sirns  Sjyeculum. — Tiiis, 
when  given  to  the  profession  a 
generation  ami  a  half  ago  by  J. 
Marion  Sims,  transformed  tlie 
art  of  gynecology,  and  i.s  to  I>e 
used  only  v^-ith  the  patient  in 
the  Sims  position  or  in  the 
kneo-ehe.st  position. 

The  orthodox  met  hew  I  of  pass- 
ing the  Sim?  speculum  is  a.s  fol- 
lows.—Tlie  operator  hol(L^  the 
^IXfulum  by  the  unuse*l  blade 
in  his  left  hanil  and  places  the 
well-anointL^l  forefinger  of  thr  right  hand,  along  the  blade  which 
is  to  Ix*  use^l,  witli  the  pahnar  surface  of  tin*  fiiiger  fitting  tlie  con- 
cavity and  thi*  tif)  projecting  jit^^t  h^yontl  the  end  of  the  bhide. 

The  tip  only  of  the  finger  entei's  the 
vulvar  cleft,  and  while  the  back  of 
the  forefinger  protects  the  sensitive 
anterior  wall  of  the  vagina  and  in* 
troitus,  the  l)lade  is  pushed  into  the 
vagina  Ijy  pressure  froru  the  thumb 
of  the  right  hand  on  the  imse  of  the 
blailc,  the  miu^erl  jjlaile  lx*ing  at 
the  same  time  transferreil  from  the 
opemtor^s  left  hand  to  tlie  right 
hand  of  an  assistant. 

Another  and  preferable  way  is  to 

anoint  the  left  forefinger  as  for  a 

vaginal  examination,  except   that 

the  palmar  as  well  as  tin*  ilorsal  surface  of  the  finger  is  smeareil 

with  the  lubrie^ant,  then,  hooking  the  finger  about  the  blade  of  the 

speculum,  anoint  it   from  Imse  to  tip.     Finally,  pasis  the  same 


Flo.  27. — Orn^'es  Bivalve  Speculum, 


88 


PnySICAL  EX.VMINATION 


fing<T  over  the  vulvar  floftj  intrfKlurn  its  ii]\  into  the  vao:ina,  and 
carrj"  back  tln^  pLrinrijin  far  cDOUgh  to  allow  the  tii)  of  the  spcfu- 
him  to  enter.  In  pushing  the  specukini  home  the  direction  of  the 
vagina  Is  to  he  home  m  niind^  its  axis  iKung  not  stimiij^tit  u[)ward 
in  the  axis  of  the  ]>atieet's  body,  but  directed  baekwartl  toward 
the  saernm* 

The  use  of  the  Sims  i^pecnhmi  necessitates  an  assistant,  except 
for  a  most  cursory  examination.  The  assistant  stands  on  the  left 
side  of  the  table  at  the  patient*s  baek  and  faces  squarely  the 
physician,  who  is  f^eated  in  the  ehair:  with  all  the  fingei-s  of  the 
left  hand  the  assistant  raises  the  laliium  tnajus  on  the  upper,  right 
Bidi%  holding  it  against  the  buttock  witti  the  hand  flat^  not  with 
the  ends  of  the  fingers  dug  into  the  flesh.  The  assistant's  left  arm 
rests  on  the  patient's  right  thigh.     The  right  hand  receives  the 


FlO,  28. — Sims  Speculum, 

unused  blade  of  the  speculum  after  the  other  blade  has  been  settled 
in  the  profier  place  in  the  vagina.  The  simi>lest  methotl  of  liolding 
the  speculum,  aufl  the  easiest  for  the  novice  to  learn,  is  to  grasp 
the  unused  blade  with  four  fingers  of  the  right  hand,  the  palm  of  the 
hand  iK-Ing  upward,     (See  Fig,  11,  ]>age  o;!) 

With  the  speculum  in  jjosition  air  enters  the  vagina  and  the 
pelvie  contents  gravitate  to^vard  tlie  ulidomen.  Nothing  liut  the 
jjosterior  wall  of  the  vagina  being  eovei^ed,  a  nearly  unobstructecl 
view  of  the  vagina  is  afTordetl,  Ry  moving  the  speculum  in  or  out 
or  turning  the  tip  from  side  to  side,  all  parts  of  the  vagina  may  be 
brought  into  view.  If  the  vaginal  walls  an*  redundant  some  sort,  of 
a  depressor  will  be  found  useful  For  tliis  purpose  the  Ix'st  instru- 
ment is 

The  Hunter  Depressor.— It  shoidd  have  a  flexil^le  copper  shank, 
and  a  large  and  a  small  end,  and  should  U-  silver-i>lated.     With  it 


J 


INSTRUMENTS  AND  THEIR  USE 


m 


Fig.  29. — ^HuhUt  VaginnJ  I>eprcivsor, 


one  pushes  out  of  th('  field  of  vision  the  olHtrufting  foUs  of  th** 

vagina,    1  lie  Ilmiirr   ili^pn^sHor  has  an  advantage  over  the  Sims 

ring-shapnl  dt^prcssor  in 

that  its   polishetl   silv^er 

surface  reflects  Ught  and 

therefore  aids  the  8|>e€U- 

luJTi  in  illunrniatinis:  the 
^d«*i*p  n^eessiss  of  tlie  vagina.  In  many  cases  the  uterine  dress- 
ing foreejis,  grasping  a  small  piece  of  cotton,  may  be  substituteil 
for  the  deprejs»sor.  The  smallest  speculum  which 
will  give  a  good  view  should  be  chosen  Ijccaitse 
the  nmall  instmment  docs  not  stretch  the  hymen 
and  introitus  so  much  laterally,  and  thus  a  longer 
antero-i>ostcrior  slit  is  ofx'nwl  in  which  the  smaller 
speculum  may  be  moved  about  freely.  It  is  a 
mistake  to  use  a  large  speculum  in  the  case  of  a 
tight  h>inen  or  narmw  vagina,  because  with  it 
much  less  of  the  vagina  can  be  seen  and  the  patient 
is  caused  unnec(*ssary  suffering.  The  opening  into 
the  vagina  shoukl  be  oblong,  not  circular,  and  ad- 
ditional room  is  obtained  only  by  carrying  the 
]x>sterior  wall  of  the  vagina  backward. 

Leaking  into  the  vagina  one  confirms  by  Bight 
the  infoniiation  gained  by  touch  and  gains  addi- 
tional data.  The  ruga?  are  seen,  if  i>resent,  con- 
ilitions  of  inflammation  are  note*!,  also  the  caliljer, 
length,  and  dilatability  of  the  canal  and  abnormal* 
ities  of  shape  and  new  growths.  The  character 
and  amount  of  the  discharge  with  it^  reaction, 
acid  or  alkaline;  the  cervix,  its  shape*,  size,  loca- 
tion, whetlier  lacerated^  and  if  so,  the  situation 
and  extc^it  of  the  lacemtions  as  detei-mined  hAh 
by  sight  and  by  use  of  the  sound  and  tenaciila, 
also  the  cervical  discharge,  its  character,  amount, 
and  reaction  are  all  noted.     Cover-glass  specimens 

and  cultures  from  the  discharge  may  be  made  if  necessary. 

The  Emmet  Curette  Forceps.^ — This  is  one  of  the  most  valuable  of 

the  mi=trument^  used  in  diagiiasis.     With  it  one  removes  pieces  of 
jc  from  the  uterine  cavity  for  examination  under  the  micro- 


FiG    30,— Em- 
kfft  Curette  For- 


90  PHYSICAL  EXAMINATION 

scope.    It  has  many  advantages  over  the  curette,  especially  in 

cases  of  pedunculated  growths  which  often  are  not  caught  by  the 

curette.    This  instrument  can  not  damage  the  uterine  walls,  as  it 

does  nothing  more  than  pinch  the  bits  of  tissue  which  project 

above  the  sm^ace  of  the  endometrium.    In  selecting  a  curette 

forceps  care  should  be  exercised  to  have  the  jaws 

J^  ground  true   so  that   they  fit  accurately  together. 

ll  Many  of  the  instruments  on  the  market  are  abso- 

^  lutely  useless  because  the  jaws  have  rounded  edges 

which  do  not  fit  accurately  one  to  the  other  over 

their  entire  length.    In  consequence  the  tissue  which 

is  engaged  between  them  slips  out  and  is  not  pinched 

tightly  and  removed  as  it  should  be. 

Except  after  labor  or  abortion  the  cervical  canal 
must  be  dilated  to  a  moderate  degree  with  Hanks 
dilators  in  order  to  admit  the  closed  jaws  of  the  for- 
ceps. When  once  in  the  uterine  cavity  the  jaws  are 
separated  and  then  brought  together  again.  Then 
they  are  removed  from  the  uterus  and  the  contents 
washed  off  in  sterile  water.  The  process  is  repeated 
imtil  the  anterior  and  posterior  walls  of  the  cavity 
have  been  gone  over  thoroughl)'  and  systematically. 

The  Uterine  Curette. — One  curette  is  sufficient  for 
all  purposes  of  diagnosis.  This  is  a  sharp  loop  of 
medium  size,  the  shaft  of  the  instrument  being  made 
of  flexible  copper  so  that  it  may  be  made  to  conform 
to  a  bent  uterine  canal.  Also  with  a  flexible  shaft 
the  danger  of  doing  damage  by  too  forcible  curetting 
is  lessened.  Following  abortion  or  dehvery  and  when 
Uterine  Cu-  ^^cre  is  flowing,  the  curette,  and  often  the  curette 
rette.  forceps  also,  may  be  introduced  through  the  cervical 

canal  without  dilatation,  except  under  such  conditions 
where  dilatation  is  necessary.  Curetting  should  only  rarely  be 
performed  without  an  anesthetic. 

Curetting. — Instruments  Needed. — Sound,  vulsellum  forceps,  Ede- 

bohls  speculum,  Hanks  dilators,  Wathen  dilator,  curette,  curette 

forceps,  two  uterine  applicators,  Bozeman's  uterine  douche  with 

irrigator  bag  and  tube. 

The  patient  is  anesthetized  with  ether,  either  preceded  by  nitrous 


INSTRUMENTS  AND  TIlErR  I'SE 


91 


\'V. 


nf  till*  (jprrator.    She 
on  a  Kelly  pail  with   biit- 


Fia.    32.— Eilebohb 
Va^nal  Spticulum. 


oxide  or  not,  accorrling  to  the  preferen 
is  placcti  in  the  lithotomy  position 
toclcs  at  the  tnige  of  the  examining  table, 
the  legs  Ix'ing  held  by  an  assisiaiit  or  by 
portable  or  fixed  leg  holilerf^.  The  binian- 
ual  touch  is  practiced.  The  \iilva,  vagi- 
na, and  surrounding  regions  are  \va^shed 
thoroughly  with  i^everal  wa.shhigs  of  soap 
and  hot  water,  then  with  alcohol,  and  final- 
ly with  sterile  water,  Ob?er\'e  that  the 
bimanual  touch  is  niaile  before  the  wa*sh- 
iiig  up.  This  is  because  the  tactile  sense 
18  less  interfered  with  when  the  vaguia  is 
lubricated  by  the  natural  .^XTctions,  Af- 
ter irrigation  and  swabbing  with  alcohol,  and  especially  with  solu- 
lioDB  of  corrosive  isubliniatc,  the  vagina  is  dry  and  clings  to  the 
finger,  sometimes  to  such  a  degree  that  the  scmsc  of  touch  is  very 
much  bhmted.  Sterile  towels  are  placfnl  about  the 
field  of  operation  and  an  Edebrjhls  weighted  specu- 
lum, previously  sterilized  with  the  other  instru- 
ments^ is  intrtxluced  into  th<i  vagina.  Tlie  anterior 
lip  of  the  cervix  is  seized  with  a  double  tenaculum 
forceps  and  the  sound  is  passed.  (For  facts  to  be 
learned  by  the  passing  of  the  sound  see  page  HO.) 
The  cer\^ix  is  dilated  by  passing  the  graduateil 
Hanks  metal  dilatoi*s.  These  are  safer  than  the 
bnmehed  steel  dilator,  which,  if  carelessly  used, 
makes  rents  in  the  uterine  walls,  more  especially 
in  the  neigh borhoml  of  the  internal  os.  These  rents 
are  not  always  recognized  by  the  operator. 

If  tlie  cervix  is  rigid  it  is  well  to  follow  the  Hanks 
dilatoi*s  with  a  steel  branched  dilator.     The  Wathen 
ililator  is  one  of  the  Ix^st  of  these.     After  it  has  been 
introduced  the  blades  are  to  be  separated  by  approx- 
imating the  handles  by  manual  iiressure,   not    by 
turning  the  set-screws,  as  is  so  often  done.     The 
reason  for  this  is  that   when  using  the  screw  the  operator  can 
not  judge  of  the  force  he  employs,  whereas,   by   manual    pres- 
sure,   he    can  e^imate    it   accurately.      When    sufficient   power 


Via,  33.— 
HatilOi  Uterioc 
Dilator. 


92 


Pm\SICAL  EXAMINATION 


has  l^een  applied  the  screw  is  turned  iiiitil   the  hiuidl(*s  arr  Ik'M 
hi  place.     ^Vfter  the  uterine  iiuisele  is  tired  the  handles  are  brought 

a  lit  tit!  nearer  together  and  the  serew 
takes  up  the  slaek.^thus  relieving  the 
ojxTator's  hands.  Fifteen  minutes  are 
necessary  for  dilatation,  more  if  the 
dilatation  is  to  be  excessive,  as  in  cases 
where  it  is  best  to  ins<:rt  the  finger  into 
the  uterine  cavity  for  purjjose  of  ex- 
[ilnration.  Dilatatioa  being  aeconi- 
plished,  the  curette  is  introduced  and 
the  walls  of  the  uterine  ea\'ity  are  gone 
over  systematically,  an- 
terior wall,  posterior  wall, 
lateral  sulci,  fumhis,  and 
r*'gion  of  the  internal 
OS.  The  eunite  forcej^s 
always  supplements  the 
curette  and  many  are  the 
IHjly|>i  wlii4'hhave  escapeil 
the  curette  that  are  seize<l 
by  tlie  curette  ff^ni^jj'"^^ 
The  cuix*tting  sliould  \x\ 
stopped  when  the  ciu^ette 
grates  on  the  firmer  sul>- 
in neons  tissue  of  the  uter- 
ine wall.  The  fettling  im- 
parted to  the  curette  is 
eharact(!ristic.  The  |>ieces 
of  tissue  ol)tainfHl  are  col- 
lected from  the  vagina  on 
swabs  of  wet  sterile*  gauze 
held  in  the  dressing  for- 
ceps and  transferred  at  oncc^  to  a  teo-per-cent  formalin 
solution,  in  which  they  are  pn\serv(Hl  for  the  fiath- 
ologist.  The  uterine  cavity  is  irrigated  freely  with 
hot  sterile  water  or  hot  salt  solution  antl  swal)lxnl 
dry  with  gauze  wound  around  a  uterine  applicator. 


lid. 


31  — UjiTluti 


I'tuniif 


Fio.  35.— 
li  o  ii  e  m  a  n  - 
Fril^seh  UttT- 
inc  Irrigalor. 

I^ozeman's 


uterine  douche  is  as  good   as  any  for  purposes  of  irrigaling  the 


1 


INSTHUMENTS  AND  THEIR  USE 


uterine  cavity,  though  in  ca.si*s  of  long  and  rigid  ccmx,  the 
Burragi^  uterine  speeuhnu  is  useful  both  for  irrigation  and  (nr 
bwabbing  the  uterine  interior.  For  packing  the  uterine  cavity 
with  gauze,  a  pnx'edim.*  sometimes  nwessttated  ui  obstinate 
hemorrhage,  this  latter  instrument  is  invahi- 
able,  for  the  gauze  Plips  easily  through  the 
metal  tube  of  the  speeulum  into  the  uter- 
ine cavity  instead  of  clinging  to  the  tissues 
of  tlic  cervical  canal 

The  vagina  is  now  proteeted  liy  [^lacing  a 
pledget  of  sterile  gauze  in  the  |)osterior  vagina 
imder  the  cervix,  and  the  uterine  cavity 
id  swabbfl  out  with  a  uterine  applicator 
wound  with  gauze  and  dijjped  in  |>in*i'  car- 

lx>lic    acid.     This    s  w  a  b  h  i  n  g 

serves  a  triple  purpos<.*:^t  an- 

tist^pticizes  the  uterine  ca\ity, 

thus    pro\iding     for     possible 

errors  in  technicjue;    it  mildly 

cauterizes  the  uterine  hiterior, 

thus  cheeking  hemorrhage:  and 

it  destroys  the  httle  islands  of 

tissue  which  have  been  missed 

by  the  curette.     By  studying 

the  interior  of  uteri  whirh  liave 

lieen  removed  by  hysterectomy 

— a  prt*vious;  cun:*tting  without 

hw*al>lnng  having  Ixhmi  don<^it 

has  lx*en  tny  experience  to  find 

that  th<»n^  are  nearly    always 

presc*nt  at  least  one  or  two  liits 

of  adventitious  tissue   left  liehind    by    the   curette. 
The  fhtngerfi  of  Curetting. — These  are:    (1)    per* 

foration  of  tlie  uteins,  a  very  considerable  danger 
in  iM^'ptic  conflitions  and  after  lalw^^r;  (2)  hemorrhage,  especially 
after  lalior  or  alxjrtion  when  the  utirine  sinusc^s  are  large;  (3)  the 
n*moval  of  t lie  entire  endometrium  and  submucous  layer  prevent- 
ing regeneration  and  causing  the  formation  of  scar  tissue  and 
fubfiequent  sterility;    and  (4)  t?eptie  infection  from  the  inocuJa- 


^ 


Fig.    36.  —  liurrap^ 
Uterine  StK^ciilunt. 


Fia.  37.— 
Uterine  Ap- 
pljcfttor. 


PHYSICAL  EXAMINATION 


tion  of  the  endonietriuni  with  septic  matter  already  there  or  iii- 
troduccil  from  without.  Perforation  is  avoided  by  using  the  great- 
est gentloness  in  <'urettiiig  septic  rases  and  in  using  the  ciu-ette 
forceps  or  the  finger  iiisteail  of  the  curette  wherever  possible. 

If  hemorrhage  oceurB,  the  uterine  ca\ity  is  to  be  irrigatetl  with 
very  hot  water  (12CP  F.),  and,  this  faihng,  it  is  to  be  packetl  with 
gauze.     For  this  purpose  a   Burrage  uterine  speculum  and  forked 

[jusher  will  t>e  found 
most,  useful.  The  re- 
moval of  the  entire 
endometrium  and  sub- 
nmeous  layer  is  avoid- 
etl  113^  observing  the  di- 
rections already  given, 
and  the  production  of 
septic  infection  by  olv 
serving  strict  asepsis 
and  by  not  operating 
during  acute  attacks 
of  t>e]vic  inflarnma- 
tioiL 
(Tu^^iil^^       ^^^t^.  UirfK^ifli^iCf^^  Digital  Exploration  of 

the  Uterine  Cavity, — 
This  is  practiced  ordi- 
narily for  complete  in- 
vestigation in  cases  of 
doubt.  The  dilatation 
is  effected  by  means  of 
tlie  Hanks  dilators^  fol- 
lowed by  the  Wathen 
dilator.  The  Bossi  uterine  dilator  or  large  stet^l  rectal  (hlators  are 
useful  for  th(^  extreme  stages  of  the  dilatation.  The  bare  finger 
sliould  l>e  employed  for  the  exploration  because  thus  the  full  ben- 
efit of  tln^  tactile  sense  is  to  be  obtained.  In  exceptional  cases, 
thase  with  rigid  cervices  where  dangrr  of  rupture  of  the  tissue  is 
great,  a  Miluable  mettiod  of  exploring  the  uterine  Ciivity  is  that 
described  most  fully  in  Dr  Howard  A,  Kelly's  ''Operative  Gyne- 
cology/' Second  Edition,  AVJ,  I.,  page  506.  An  anterior  eolpotoniy 
is  i>erformed,  the  transverse  incision  l>eing  used.    After  the  vagina 


Fig.   38. 


'//hr'1f\ 


-Transverse 
Cervix. 


Incision 


Anterior    to 


k 


J 


INSTRUMENTS  AND  THEIH  TSE 


95 


I 


and  bladder  have  been  Beparated  from  the  uterus  by  blunt  dis- 
8c*ction,  the  cervix  is  stc^adic^l  by  two  \^g5elJa  and  the  anterior  lip 
of  tile  cervix  is  divided  l>ct\vcf*n  them  with  scissors  to  a  point 
beyond  the  internal  os.  The  digital  exaruination  of  tin*  uterine 
interior  conipletnl,  the  divided  uterine  walls  are  brought  together 
with  sutures  and  the  vagina  is  then  replaeed  and  sutured.  In  my 
exj>erienfe,  a  eertaiu  amount  of  preliminary  dilatation  of  the  cervix 
facilitates   this  opera- 


ii^ 


h 


vV^>A 


an 

■  tu 

I  "' 

■  tei 


^^ 


lion.  (See  Figs.  38-li;) 

The  remaining  in- 
struments in  the  ex- 
amin<T*s  kit,  nanu-ly, 
thos4»  for  thf  JTivesti- 
gation  of  tlie  urethra, 
bladder,  and  lurtei's, 
and  those  for  the  nx- 
aminatit»n  of  the  rec- 
tum, will  Ije  d(\<erilHMl 
in  the  succeeding  rha[H 
tens  devotcil   to  thesi^ 

l)jects. 

Pelvimetry.  — The 
gynecologist  is  frt*- 
qucntly  consulted  by 
women  who  wisli  to 
know  whether  they 
Fiavc  any  jx^lvic  de- 
formity that  would  Ix' 
a  hindmnfe  to  then- 
having  cliiltlren,  also 
by  tlioee  who  are  already  pregnant  with  the  same  query,  there- 
fore it  sei*ms  besi  to  deserihe  the  measurement  of  the  pelvis.  B. 
C.  Hirst  (**  r)is<*ai^*s  of  Women/'  p.  419)  thinks  that  tleformed 
pelves  occur  in  about  seven  per  cent  of  the  wliite  women  of  large 
American  cities,  but  that  they  are  comparatively  infrfMjuent  among 
the  upper  clas«\s  and  iu  thf*  rural  agricultural  districts,  while 
frwjuent  among  negrof^s.  A  general  pnietitiouer  in  a  city  can 
hardly  hope?  to  avoid  seeing  eases  of  pelvic  deformity.  For  the 
many  fonns  of  pelvic  deformities  the  reader  is  advised  to  consult  a 


hmW 


\yjf' 


Fig.    m. 


-Incising    the    Ant^^riar 
tVrviv.      i  Kelly.) 


W^ali   of    thr 


1 


96 


PHYSICAL  EXAMINATION 


9 


\K\ 


I 


^1 


modem  tcxHx>ok  on  olistetrics.  The  commonest  forms  are  simple 
flat  pelvis,  generally  equally  contracted  pelvin  {justominor},  and 
generally  contrarted  fiat  i^elvis.  Tht^se  arc  all  due  to  faulty  devel- 
opment of  the  skeleton.  The  other  rarer  forms  are  eaused  by 
disease  of  the  pel\dc  bones  and  anomalies  in  the  sacro-iliac  and 
pubic  joints. 

To  practice  pelvimetry  successfully  one  must  have  a  reliable 
tape  measure  and  a  pelvimeter.     The  latter  is  a  large  pair  of 

calipei-s  with  a  iseale  divided  into  cen- 
timeters antl  inches.  The  mea.sure- 
ments  to  be  made  are  the  antero- 
posterior iliameter  of  the  superior 
strait,  the  capacity  of  the  jx^lvic  cav- 
ity, and  the  transv<*i'sr  diameter  of  the 
jielvic  outlet.  In  exceptional  ais*\s  of 
oblicjuely  contracted  pelvis  it  may  he 
necessary  to  measure  the  obHiine  di- 
a^^oiial  diameters  of  the  pelvic  inlet. 
The  patient  must  be  prepared  as  for  a 
\'aginal  examination  and  should  be  in- 
spected f  first  in  the  standing  position  to 
note  tlie  posture^  shape  of  the  back, 
and  inclination  of  the  pelvis. 

Exlemal  or  Baiuldocque's  Confugate 
Diameter  (8  inches^  or  20.5  centi- 
meters). ^()n  inspecting  the  standing 
woman  from  Ix'hind,  one  sees  in  some 
cases,  not  in  all,  Miehaelis'  rhomlxiid, 
a  lozenge  or  diamontl-shai>cd  surface 
on  the  skin  at  the  l)ase  of  the  spine. 
The  four  j joints  making  the  diamonfl 
are: — on  the  sides,  a  ilepressio!i  at  each  upper  comer  of  the 
sacrum;  at  tlie  bottom,  tlie  notch  between  the  l>uttocks;  and 
at  the  top,  the  depression  over  the  spine  of  the  fifth  lumljar  ver- 
tebra. If  this  ilepi-ession  can  not  h^  sc*en,  the  spines  of  the 
vertebra*  are  felt  l)y  the  finger  from  alx)ve  downward  until  the 
last  one  is  ivached.  T\\v  tiji  of  the  pelvimeter,  guided  into  place 
by  the  physician's  finger,  is  jilaced  in  the  depression  just  below 
the  last  spine.     The  other  point  of  the  f)elvimeter  is  placed  on 


i 


Fm.  40.— TTtcrine  Ca\-ity  Laid 
Oiieii.     (Kelly.) 


J 


INSTRUMENTS  AND  THEIR  USE 


97 


'/^" 


"^i 


the  anterior  upper  margin  of  the  sympliyFis  pubis,  exactly  in 
the  middle  line.  Firm  pressure  is  made  and  the  reading  on  the 
scale  of  the  pelvimeter  i.H  taken.  The  true  conjugate  can  not  he 
estimate*]  accurately  from  the  external  conjugate  because  of  the 
uneven  thickness  of  the  pi»Ivic 
fxines  in  difTerent  individual^, 
and  also  txTaas<^  of  the  varying 
obli<juity  of  the  pubic  fjone.  An 
extenial  conjugate  of  6^  inches, 
16  centimeter^,  or  under,  means 
Furely  an  antero-[>ogterior  con* 
traeted  pelvis,  anything  over  8 
inches?^,  20.5  centimeters,  is  nor- 
mal or  large. 

The  ohlu/ue  canptgaie  diatfwter 
(5J  inches,  or  12.8  centimeters), 
or  the  distance  imni  the  prom- 
ontorj'  of  the  8acrum  to  the 
under  margin  of  the  sjmjthysis 
pubi?^  may  be  measuretl  b}-  ex- 
amining the  woman  in  thefloi-sal 
l>asitiom  Two  fingers  of  tlie  k^ft 
hand  are  introduceil  into  the  va- 
gina and  the  middle  of  the  prom- 
ontory of  the  sacrum  n*ache<i 
with  the  ti|>  of  the  middie  finger. 
Be*  cart*ful  not  to  mi^'take  the  las^t 
luml>ar  for  the  first  sacral  ver- 
ti*bra  and  be*  gentle  and  not  too 
r»ind  in  performing  this  ma- 
nipulation, \\  ilh  the  tip  of  the 
forefinger  of  the  right  hand, 
mark  the  point  at  the  base  of 
the  thumb  of  llje  left  hand 
touched  by  the  lower  edge  of  the  symphysis.  After  the  hand  has 
been  remove<i,  tlie  distance  Ix'tween  the  tip  of  the  middle  finger 
and  tlxis:  point  is  measun*d  by  the  tape  measure.  Subtract  from 
this  }  of  an  inrli,  or  1.75  centimeters  (representing  the  thick- 
ness of  the  symphysis),  to  obtain  the  true  conjugate.  The 
7 


f 


Fio.  41. — Exploring   I'teriiie   Cavity 
with  Fingtfr.     (Kt^lly,) 


PHYSICAL  EXAMINATION 


measurement  of  the  normal  true  conjugate  is   4f  inches,  or  11 
centimeters. 

T}ie  transverse  diameter  (5f  inches,  or  13.5  centimeters). — ^This 
diameter  is  inferred  from  measurements  of  the  iliac  bones.  The 
distance  between  the  anterior  superior  spinous  processes  of  the 
iHa  in  well-formed  women  is  lOi  inches,  or  26  centimeters;  the 
distance  between  the  crests  of  the  ilia  at  their  widest  points  is  11^ 

niches,  or  29  centimeters;  the  dis- 
tance between  the  trochanters  is 
12J  inches,  or  31  centimeters.  In 
making  these  measurements  the 
patient  is  in  the  dorsal  position, 
but  with  the  thighs  extended. 

The  Transverse  Diameter  of  tlie 
Outlet  (4|  inches,  or  11  centime- 
ters) . — ^This  is  the  distance  betwet»n 
the  tuberosities  of  the  ischia  and 
is  measured  with  the  patient  in 
the  lithotomy  {)osition,  the  pelvi- 
meter being  employed  as  in  the 
other  external  measurements. 

The  Capacity  of  the  Pelvic  Cav- 
ity.— This  is  an  estimate  fonned 
by  vaginal  examination  with  two 
fingers  in  the  vagina.  When  the 
oblique  conjugate  is  being  measured  the  opportunity  should  be 
seized  to  palpate  the  interior  of  the  pelvis  and  form  an  idea  of  its 
capacity,  as  well  as  a  search  made  for  abnormalities  in  the  shape 
of  new  growths,  old  fractur(\s,  caries,  or  necrosis. 

Tlie  Oblique  Diagonal  Diameters  (8J  to  9J  inches,  or  22  to  23 
centimeters). — ^These  are  measured  by  the  pelvimeter  with  the 
patient  lying  first  on  one  side  and  then  on  the  other.  One  end  of 
the  pelvimeter  is  placed  on  the  j^osterior  superior  iliac  spine  on  one 
side  and  on  the  anterior  superior  iliac  spine  on  the  other.  The 
right  obli(iue  diagonal  is  generally  a  trifle  longer  than  the  left. 
The  posterior  superior  spinous  processes  are  often  marked  by 
distinct  dimples  on  the  woman \s  back. 


Fio.  42. — The  Pelvimeter. 


CHAPTER  VIII 

:he  investigation  of  the  urethra,  bladder,  an!) 

URETERS 

Iiistnimerits  ust^\,  p>  *M. 

Anatomy,  |»,  HM),  Tiie  un^thni,  p.  KKI.  The  blfuliltT.  [).  li»L  Luncl- 
uiiirkii  in  the  bla*J<lrr»  p.  UH.     The  uivters,  p,  HJL 

ThecxmnitiuHon,  p.  107,  UathHtTization  of  the  hlitthlcr,  ]».  lOH.  Search- 
ing ihe  urelhrii  and  the  bladder,  p.  1(*H,  l)iref[  eiidnscupy  and  evstoseojiy 
irilh  air  dislendeil  urt*thni  and  bhidder,  p.  I HK  Uatheteriwition  of  Ihe 
uretefB*  p.  ll.>.  Indirect  cystosccjpy  with  waler  disleiideil  bhidder,  p.  117. 
Cfaromocystoscopy,  p.  I  ll>. 

Ix  this  chapter  wr  wnll  consi<h'r  only  dirnrt  uri'lhrosoopy  and 
cv>to*4co[>y  by  nican.s  of  a  sirn]jl('  tubc^  (tliu  Kelly  cy^sto^scopi*)  anil 
n>flf*cted  U^ht,  a.s  a  moans  for  tin*  inspection  i>f  the  iirethi*a  and 
bla(ldf*r,  for  it  has  bc^en  found  in  the  anther's  exiierienee,  to  inirt 
sati^^facturiIy  ttie  ^}7ieeolopst 's  n*f|uiretnents  for  diagnoms,  Morc^ 
over,  the  nietho<I  is  easily  learne<i  and  simpler  than  cystos^i-opy  with 
a  Nitze  cystoscoix?  or  instrument  of  that  class,  by  which  an  electric 
lamp  IS  introducefi  into  the  water-dist funded  bladder.  As  irnlirect, 
ek*ctric  cysto«*copy  la  api>IiraK>le  cx-casiunally  where  the  air-ciis- 
tended  b!a<lder  methotl  can  not  well  be  used,  and  as  many  physicians 
prefer  it  as  a  nK*tho<l  of  diapiosis,  I  have  added  as  an  appendix  a 
de.*?cription  of  the  stc|*s  of  tliis  sort  of  eystascopy  as  I  liave  i*een  it 
etnploycM.1  in  competent  hands. 


INSTRUMENTS   USED 

Silver  female  catheter*  long. 

KrlW  meatus  calibrator 

Kelly  .st<M^I  urethral  ?<ounds,  one  set. 

Kelly  cyt<toscopK?s,  Nos.  8,  10,  and  12, 

Kelly  ureteral  seajcher 


i 


100  THE  URETHRA,  BLADDER,  AND  URETERS 

Two  Kelly  ureteral  catheters. 

Rubber  bulb  and  tube  for  suction. 

Alligator  bladder  forceps. 

Uterine  applicator. 

Sims  speculum. 

Head  mirror. 

To  this  list  of  instruments  are  added: 

A  sterile  ten-f^r-cent  solution  of  cocaine  hydrochlorate  in  water. 

A  sterile  four-per-cent  solution  of  boric  acid. 

Absorbent  cotton. 

A  sterile  eight-ounce  bottle  with  stopper. 

Two  sterile  two-ounce  bottles  with  stoppers. 

A  two-quart  fountain  syringe,  and  a 

Collapsible  tube  of  lubrichondrin,  or  K-Y  jelly. 

Not  every  woman  who  complains  of  urinary  symptoms  is  to  be 
subjected  to  a  cystoscopic  examination.  For  instance,  frequency 
of  micturition  associated  with  early  pregnancy,  although  not  pre- 
cisely normal,  generally  represents  increased  congestion  of  the 
upper  urethra  and  the  neck  of  the  bladder,  due  to  the  pregnant 
state,  and  is  to  be  disregarded,  unless  the  symptoms  are  so  severe 
that  they  undermines  the  health  by  interfering  with  rest  and  sleej). 
Only  when  urinary  symptoms  are  persistent  as  well  as  severe,  are 
the  urinary  organs  to  be  investigated. 

Before  proceeding  to  the  examination  let  us  review  the  salient 
features  of  the  anatomy  of  the  urethra,  bladder,  and  ureters. 


ANATOMY 

The  Urethra. — The  urethra  is  a  membranous  canal  varying 
from  an  inch  and  a  (quarter  to  an  inch  and  a  half  in  length 
(3  to  3.5  centimeters)  extending  from  the  meatus  urinarius  to 
the  neck  of  the  bladder.  It  lies  under  th(»  arch  of  the  pubes, 
its  lower  extremity  being  separated  from  the  pubic  bone  by 
about  four-tenths  of  an  inch  (1  centimeter).  It  is  parallel  with 
the  vagina  and  is  embedded  in  its  wall,  its  course  behig  slightly 
curved,  the  concavity  directed  forward  and  upward.  Its  diame- 
ter when  undilated  is  about  a  cjuarter  of  an  inch  (6  millimeters). 


ANATOMY 


101 


The  meatus  urinarius  opens  into  the  vestibule  just  alx)vc  the  open- 
ing of  the  vagina. 

In  virgins  the  meatus  m  a  vertical  slit  about  a  fifth  nf  an  inch 
long,  formed  by  two  little  lips  which  clos*^  the  orifice  and  jiroteet 
it  from  infection.     In  old   women   the^e  lips  are 
lack  Lug.  Jj 

The    waU    of  the    urethra    consisting    of    three  ^ 

coats,  muscular,  erectile,  and  nuie<»us,  is  about  onc^ 
fifth  of  an  inch  thick  and  is  dilatable  to  a  consider- 
able degree,  the  meatus  lieiiig  the  most  resistant 
part.  It  is  not  safe,  liowever,  to  dilate  the  urethra 
beyond  twice  its  normal  diameter,  i.e.,  beyon<^l  half 
an  inch  (12  millimeters),  becaiLse  of 
the  danger  of  permanent  inconti- 
nence of  urme. 

When  the  urethra  is  not  distende<^l 
the  mucous  coat  is  throwTi  into 
longitudinal  folils,  one  of  which, 
pla<:*t*d  along  the  fif>or  of  the  canal, 
R'sembles  the  venmiontanum  in  the 
male  urethra.  The  canal  is  lineal 
with  stratified  epithelium,  which  be- 
comes transitional  near  the  bladder. 
In  the  floor  of  the  urethra  are 
two  little  tubular  glands,  half  an 
inch  long  anil  about  a  thirty- 
second  of  an  inch  in  diameter, 
placed  ]ength"Wis(%  with  their  ori- 
fices at  the  rnt*atus,  just  within  or 
upon  the  labia  uretlu-a^.  These 
are  Skene's  glands.  It  is  thought 
that  the  function  of  these  glands 
is  to  secrete  a  hibricating  mucus  to  protect  the 
meatus  from  trauma  during  coitus. 

The  Bladder.—TIie  bladder,  a  musculo-mem- 
branous  siic  emlM*dded  hi  connective  tissue,  when 
quite  empty  and  contracted  is  cui>shaped,  and 
cm  vertical  median  section  its  cavity,  with  the  adjacent  portion  of 
the  uiethra,  presents  a  Y-shaped  cleft,  the  stem  of  the  Y  corre- 


Fio.  43.— 
Silver  Fvrnale 
ratheter. 


Pro.  44.— Kel 
'%f  AfentUA  Call 


102 


THE  URETHIM,  BLADDER.    AND  T^RETERS 


e^pomling  to  the  iirethra.  Whvn  .slightly  distenikMl  ihv  l>Ia<ltler 
has  a  roiDidod  form  and  18  stili  (contained  within  the  cavity  of 
the  pc^Ivis  :  when  greatly  disteiuled  it  is  ovoid  in  shape,  ris<"s 
into  the  abdoiiunal  cavity^  and  may  reach  as  high  a.s  the 
umbi liens.     Its  capacity  is  al)out  a  pint. 

For  pnrposes  of  desc Hfitioo  the  bladder  may 
be  tlivided  into  a  }?yperior»  an  antero-inffrior, 
anil  two  lateral  surfaces,  also  a  base  or  fundns, 
and  a  summit  or  apex. 

The  superior,  or  alwlorninal  surface,  is  fnx* 
tow^ard   the  peritoneal  cavity   and  is   covered 
with  peritoneum;   the  antero-inferior  portion 
looks  tow^anl  the  posterior  surface  of  the  s}in- 
physis  pul)is  and  is  uncovered  by  peritoneum; 
the  lateral  surfaces  are  covered  by  peiitoneum 
except  in  their  lower  portions  where  they  come 
in  contact  with  the  liroad  ligaments;  the  fuuflus 
or  base  of  the  blatUler  is  directed  ilownwaRl  aiul 
backw^ard  antl  is  partly  covered  by  jjeritoneum 
and  partly  uncovered.    It  is  connected  with  the 
anterior  a^fiect  of  the  cervix  and  with  tlie  an- 
terior wall  of  the  vagina  liy  areolar  tissue*  the 
union  lMl\ve<'n  the  bladdei*  ami  vagina  brnng 
closer  than  that  betwc^en  tlu^  bladd(U"  and  cer- 
vix.     The  upper  portions  of  tht;  bladder  are   more  movable 
than  the  lower  and  when  viewed  through  the  cystoscope  may 
be  seen  to  move  wdth  respij^ation. 
The  so-called  neck  of  the  bladder  is  the  jioint  of  beginning 

of  the  urethra, 
^^     ^  true  neck,  as  t 

g  1  tapering    jiart. 

M  1  ^     tonic     contrac- 

I  .^^^    \         muscrular    ^^ 

1            ^^^^^^     ft  ^'^ 

\         ^^^^^IP    J  ^'-^'  bladder  wall  at  this  point  prevents  the 

V^    ^^^^  Jf  e^ape of  urine. 

^^^^^^^^^  The  bladder  is  composed  of  four  coats: 

Fig*  46.— Kelly  Evacuator.  serous,nmscy!ar,  submucous^  and  mucous. 


Fig.  4r>.— The 
Kt'lly  Doiilile- 
cntU'd  Urethral 
Dilalor. 


AXATOMY 


103 


The  serous  coat  is  derivetl  from  the  |>eritoiieuni  and 
is  therefore  partial:  the  muscular  t/oat  is  made  up  of 
three  layera  of  unstrijK'd  iiiusrular{ilin\  two  of  thoni 
Ix^ing  lon^itiidbml,  and  on<',  t'ireular  in  direction :  the 
submucous  coat  is  the  alveolar  tis.sue  whieh  connects 
the  inuseular  with  the  niucdus  coat.  The  mucous  coat 
is  thin,  smooth^  aiiti  of  a  pale  rose  r-olor,  and  is  tlirov^n 
into  fokis  or  rug:e  when  the  bladder  is  empty.  There 
are  no  true  glands  in  the  mucous  meintirane, 

Utndmarkfi  in  (he  Bladder. — \\  lu-n  the  bladder  is 
distended  with  air  it  forms  a  hollow  sphere.  The  in- 
ternal orifice  of  the  urethra  or  neck  of  the  bladder  is 
a  deftnite  landmark  to  be  recognized  by  the  obscTVer 
looking  through  the  cyst(>sco|K?  as  the  fij*st  portion 
of  mucous  membrane  wliich  rolls  into  the  kwiien  of 
the  cyj?tascope  as  its  end  is  withtlrawTi  through  the 
uretlira.  The  ureteral  orifices  are  two  muiute  open- 
ings situateil  in  small  elevations  of  the  mucous  mem- 
brane of  the  blatMer  (mons  ur(*teris),  an  inch  a|>art, 
one  on  each  side  of  the  median  line  ami  each  thrtv- 
(juartersof  an  inch  (2  centimeters)  from  the  internal 
orifice  of  tlit*  urethra.  These  tlirec  points  mark  out 
the  trigone  of  the  bladder. 

There  is  sometiTn**s  seen  the  interureteric  liga- 
ment, a  distinct  fold  elevatefl  al:K>ve  the  level  of 
the  surroumUng  nuicosa  comiecting  the  ureteral 
orifices. 

The  l(X*ation  of  lesions  in  the  hla<Ider  is  described 
by  means  of  the^*  lautlnmrks  antl  by  the  natural 
divisions  of  the  bla<Ider  alrea<ly  given. 

The  Ureters.— The  un^ters  are  two  cylinrlrical  mem- 
branous  tulxs  lying  in  the  loose  connective  tissue 
behind  the  aUlominal  and  jK-lvic  peritoneum,  about 
three-sixteenths  of  an  inch  (6  millimeters)  in  diameter 
and  tw^elve  inches  (30  centimeters)  long,  extending 
from  the  [x^lvis  of  the  kidneys  to  the  bladder.  The 
tngth  of  the  ureters  tlejx*nfls  in  some  measure  on  the 
length  of  the  trunk.  A  jjatient  having  a  long  trunk 
will  have  correspondingly  long   uif ters.      Different 


-x- 


Fic.  48 — 
Kelly  Ure- 
teral Cath- 
eter. 


104 


THE  UHKTHRA,  BLADDER,  AND  URETERS 


authorities  give  the  length  of  the  urt^ters  all  the  way  from  ten  to 
sixteen  inches  (25  to  40  centimeters).  The  left  ureter  is  a  little 
longer  than  the  right  bcH:ause  of  the  liiglier  position  of  the  left 
kidney.  The  ureter  is  funnel-shaped  as  it  leaves  the  pehds  of  the 
kidney  and  then  the  huuen  has  a  diameter  of  an  eighth  of  an 
inch  (2  millimeters),  imtil  the  ureter  reaches  its  termination  in 
the  bladder  wall,  where  there  is  a  narrowing,  which  beeomes  a 
complete  closure  when  ttie   bladder  is  distended.      This  closure 


FiQ.  49.— Kelly  Cystoacope  with  Obturator. 

is  effected  by  the  oblique  insertion  of  the  ureter  in  the  bladder 
wall,  the  mucosa  and  ant<'i'ior  portion  of  the  l)Iadder  wall  forming 
with  the  upper  side  of  the  ureter  a  wetlge-slmped  valve,  the  ai3ex 
of  the  wedge  Ix'ing  at  tlie  ureteral  orifice. 

The  ureter  lies  on  the  psoas  muscle  throughout  its  abdonunal 
course,  at  the  brim  of  the  pelvis  it  lies  on  the  conmion  iliac 
artery.  Withm  the  jx^vis  it  nms  dovraward  just  outside  the  in- 
ternal iliac  artery,  and  then,  turning  forward  and  crossing  under 
the  uterine  artery,  it  passes  half-way  between  the  pelvic  wall  and 


ANATOMY 


105 


the  cervix,  at  a  distance  of  alwut  half  an 
ijich  from  the  latt-er,  under  the  Imse  of  the  broar  I 
ligament  to  the  IJadder.  The  ureter  is  com- 
posed of  three  coatt?,  fibrous,  muscular,  anil  mu- 
cous. The  fibi-ous  coat  h  continuous  with  the 
caprnde  of  the  kidney  above  and' is  lost  in  the 
bladder  wall  Ix'low;  the  muscular  coat  of  the 
ureter  proper  is  made  up  of  three  laytTs:  exter- 
nal, internal  longitudinal, and  middle  ciiTular;  the 
mucous  coat  issuionth  and  has  a  few  longitudinal 
folib.  It  is  continuous  with  tlie  mucosa  of  the 
bladder  below  and  the  pelvis  of  the  kidney 
above,  and  is  comfjosed  of  several  layers  of  cells. 

The  ureters  transmit  the  urine  from  the  kid- 
ne>^  to  the  bladder  intermittently  l:>y  means  of 
peristaltic  waves  traveling  the  length  of  the 
ureter.  Tlirough  the  cystoscope  the  urine  may 
be  seen  to  issue  from  the  ureteral  orifices  in 
little  spurts  and  the  ureteral  orifices  may  be 
seen  to  expand  and  contract,  the  spurts  being 
more  foiTihle  and  more  frerjuent  with  greater 
activity  of  the  kiilneys,  the  normal  rate  btnng 
all  the  way  from  one  spurt  every  ten  seconds 
to  a  spurt  every  sixty  seconds. 

Obeer\^ations  have  lx»en  reconhxl  which  tend  to 
prove  that  the  movements  of  the  orifice  are  leas 
frecjiient  when  the  kidney  on  tliat  side  is  func- 
tionally inactive.  Infection  

travels  from  the  bladder  up 
the  ureter  only  when  the 
valve-liko  arrangement  at 
the  orifice  in  the  bladder 
has  been  dei?troyed,  or 
when  infective  material 
has  been  introduced  into 
the  ureter,  as  on  a  ureteral 
catheter  or  bougie,  f^^^  50,^Amgi,tor  Biiwldcr  Foro^^ 


Fro-   ')L— Tlie  Normal  Filiniarr.  Lai-1  Oprn  frnm  the*  Front.     (Kelly;) 


external  f^rnilals  are  iiispfTtt*(l  an<l  a  sharp  lookout  is  excrcistMl  for 
eviticnri^is  of  gonorrhea,  for  rczeniatoiis  skin  legions,  or  abnormali- 
ties of  the  meatus, 

Redjiess  alx)ut  the  meatus  antl  the  orifices  of  the  glands  of 
Skene  and  Bartholin,  with  the  [rossihility  of  expresshig  a  drop 
or  two  of  pus  from  the  uretlira  by  stroking  its  coui-jsu  tlirough 


THE  EX.\MINAT10N 


107 


the  wall  of  tlir  vti^iiia,  inakfH  gonorrhnv  rnfjst  pn>l>ablc%  iUm- 
orrhea.  being  BUPpec^twl,  no  iiistruiiieiit  nhould  lx>  passed  beyond 
the  bladder  neck  for  fear  of  carrvhi^  infection    iiitn  that  nr^an. 

InsiHH'tion  shows  whether  tln^  laljia  urethne,  which  nornmlly 
close  the  nu*atu8  in  vii*gins^  ar(^  in  ap|josition  or  separatiHl;  shows 
the  pix'senre  of  a  urethral  caruncle  or  prolapse  of  the  mueous 
nu-rnbrane  of  the  urethm  or  a  tumor  in  the  urethra  projecting 
through  the  meatus.  Inspection  also  shows  eczenm  of  the  vulva 
caused  by  the  urine  of  dialx^tes  niellitus. 

Paljiation  Iiy  the  left  forefinger  in  the  vatrina  reveals  thieketiintr 
of  the  urethra  and  tendrrTns>  nt  any  poitit»n  of  its  course,  also  a 


Fio-  52. — Urine  ^urtinie  from  Ureteral  Orifice,  as  Set*n   through  Cystt>srope. 

I  Kfiorr.) 


suburethral  abBcess  or  tumor,  and  the  liinianual  touch  reveals 
thickening  of  the  blatlder  walls,  a  stone  in  the  b!add(T.  i>oiots  of 
tenderaesas,  a  distend(*d  bladtier,  or  a  vesiecvvagina!  hstula.  P(»r- 
cusgion  over  the  pulx'S  delermines  an  area  of  dullness  correspontling 
to  a  di.stended  bladder.  The  bimanual  touch  niay  reveal  tenderness 
of  the  jx'lvic  portion  of  the  ureter  or  thickening:  of  the  ureter  in  this 
part  of  its  coui*se»  or  a  stone  in  the  ureter. 

To  n^ach  the  upper  portion  of  the  j)elvic  portion  of  the  ureter  the 
recto-atxloininal  binianual  touch  is  best.  Thin  an<l  relaxeil  alv 
ciominal  walls  art*  a  necessity  for  success  in  tliis  field  of  uivesti^a- 
tion,  although  a  thickened  ureter  niay  be  palpated  in  the  lowest 
tiro  inches  of  it^  coui'se  by  a  digital  vaginal  examination,  and, 
exceptionally,  a  thickened  ureter  may  be  seen  as  a  ridge  m  the 


108  THE  URETHRA,  BLADDER,  AND  URETERS 

vaginal  mucous  membrane  on  speculum  examination  of  the  vagina. 
Palpation  having  furnished  what  information  it  will,  the  next  step 
is  the  passage  of  the  silver  catheter. 

Catheterization. — I  prefer  a  long  catheter  of  small  caliber,  because 
it  may  be  used  both  as  a  searcher  of  the  urethra  and  bladder  as 
well  as  a  catheter.  The  meatus,  vestibule,  and  inner  surfaces  of 
the  nymphae  are  sponged  with  three  or  four  pledgets  of  cotton 
soaked  in  sterile  water  or  weak  creolin  solution,  each  pledget  being 
thrown  away  as  soon  as  it  has  been  used  once.  That  is,  a  piece  of 
cotton  is  never  dipped  a  second  time  in  the  water.  Normally  the 
urethra,  as  in  the  case  of  the  vagina,  except  just  inside  the  external 
opening,  is  free  from  bacteria.  Well  lubricated,  the  sterile  catheter 
is  passed  gently  into  the  bladder,  the  direction  of  the  urethra  being 
borne  in  mind,  at  first  backward  parallel  with  the  axis  of  the 
vagina  until  the  bladder  neck  is  reached,  and  then  forward.  Care 
should  be  taken  not  to  touch  the  outer  end  of  the  catheter  before 
the  urine  is  collected,  and  the  lubricating  should  be  done  directly 
from  the  collapsible  tube  without  the  intervention  of  the  physician's 
fingers. 

The  urine  from  the  bladder  is  collected  in  the  sterile  eight-ounce 
bottle  for  analysis,  note  being  made  of  the  character  of  the  urine 
as  it  flows  from  the  catheter,  whether  clear,  cloudy,  or  bloody. 
Blood  at  the  beginning  indicates  that  its  source  is  the  ureter  or  kid- 
ney. Also  whether  the  last  part  is  cloudy,  showing  residual  pus; 
and  the  force  of  the  stream,  increased  in  distended  bladder  and  in 
cases  of  pressure  on  the  bladder  by  tumors  or  straining,  decreasetl 
in  atonic  bladder.  Suprapubic  pressure  may  ha  necessary  to 
empty  such  a  bladder. 

Searching  the  Urethra  and  Bladder. — ^After  the  urine  has  been 
withdrawn  the  catheter  is  used  as  a  searcher,  the  greatest  gentleness 
being  employed.  The  bladder  walls  are  gone  over  systematically 
and  points  of  tenderness  noted.  With  a  finger  in  the  vagina  and 
the  searcher  catheter  in  the  bladder  the  thickness  of  the  bladder 
wall  at  the  base  is  estimated;  a  stone,  foreign  body,  or  phosphatic 
deposits  are  detected  by  a  gritting  sensation  transmitted  to  the 
catheter,  or,  in  the  case  of  a  stone,  by  a  metallic  click;  sometimes 
a  tumor  is  diagnosed  in  this  way.  In  cases  of  cystitis  it  is  not  wise 
to  sound  the  bladder  at  the  same  time  that  a  cystoscopic  examina- 
tion is  to  be  made  because  the  slightest  trauma  will  cause  bleeding. 


SEARCHING  THE  URETHRA  AND  BLADDER 


100 


The  discharge  of  blocxl  through  the  catheter  at  the  end  of  eatheter- 
izatioa  is  a  diagnostic  sign  of  cystitis. 

If  there  is  suspicion  that  tlie  bladder  is  contracted,  its  capacity 
may  l>e  measures!  by  injecting  with  th<^  fountain-s>Tinge  tul>e 
attached  to  the  catlieter,  wann,  sterile,  one-per-cent  boric-aciil 
solution  until  the  patient  has  a  strong  liesbx*  to  urinate*  Tlien 
disconnect  the  syringe  tutie  and  collect  and  measure  the  water 
issuing  from  the  catheter*  In  cases  of  cystitis  it  is  mse  to  irrigate 
thebladfier  with  l>oric-acid  solution  l3efore  ending  the  examination. 
For  this  purpose  the  process  just  descril>ed  is  re{x*ated  several  times. 
It  is  to  1k^  noted  that  the  catheter  has  not  \wvn  removed  from  the 
bladder  since  it  was  introduced,  thus  a  minimum  of  trauma  h 
inHiciecl  on  the  uretlira  and  vesical  neck. 

The  bla<ider  searching  lifnng  finished,  the  cat  better  is  withdrawn 
slowly;  clonic  spasm  of  the  I)[ailder  walls  is  noted  in  some  cases, 
indjeated  by  a  druniining  of  the  movable  upper  portion  of  the 
bla^lder  on  the  less  movable  base.  If  the  bladder  is  irritable  or  the 
muscular  fibres  ln*]K*rtroplnefl,  the  catheter  is  seizerl  w^ith  greater 
firmness  at  the  bladder  neck  as  it  is  withdrawn. 

When  the  eml  of  the  catheter  reaches  the  urethra  one  notes: 
pcjints  of  t^^ndemess,  pouches  in  the  mucous  membrane  or  abnormal 
size  in  the  lumen,  also  stricture,  by  no  means  rare,  its  situation  and 
relative  size.  With  a  finger  in  the  vagina  anti  the  end  of  the 
catheter  in  the  urt-tlu-a  one  determines  the  thickness  of  the  walls  of 
the  uiTthra,  the  extent  of  an}*  |)ouching  of  the  mucous  nieml>rane, 
due  to  rupturi'  of  the  walls  frorri  trauma  during  ik4ivi*ry,  and  also 
diJilocation  of  the  urethra  downward.  This  is  a  common  deformity 
iud  one  oft-en  overlook*^  1.  To  detect  it  the  investigator  observes 
wluHher  the  urethra  Is  in  close  relation  with  the  under  surface  of 
the  arch  of  the  pulses  as  it  should  Ix'  normally,  or  far  away  from  it, 
ai»  it  is  when  dislocated.  In  cases  of  prolapse  of  the  uterus  the 
urt'thra,  together  with  the  Ijlaildcr,  is  conmionly  dislocateil  to  a 
variable  degree.  Suppose  the  upper  tliird  of  the  urethra  is  dis- 
locatiHJ  down  wan  I  with  the  blad^ler.  The  catheter  is  passed  into 
the  urethra  most  gently  until  it  meets  the  obstruction  of  the  down- 
ward Jx*nd  of  the  urethra.  The  point  of  the  catheter  is  noted  by 
[j&i]>ation  by  a  finger  iji  the  vagina  and  thus  the  situation  of  the 
beginnmg  of  the  disI<x'ation  is  determininj. 

In  the  caae  of  procidentia,  if  the  blatlder  is  dislocated  a  curved 


110  THE  URETHRA,  BLADDER,  AND  URETERS 

uterine  sound  is  to  be  substituted  for  the  catheter  and  the  situation 
of  its  point,  as  felt  by  the  finger,  marks  the  lower  limits  of  the 
bladder  in  the  prolapsed  mass. 

Having  gained  all  the  facts  possible  by  the  use  of  the  catheter, 
the  next  proceeding  is  inspection  of  the  urethra  and  bladder. 

Direct  Endoscopy  (Inspection  of  the  Urethra),  and  Direct  Cysto- 
scopy (Inspection  of  the  Bladder). — The  patient  is  in  the  dor- 
sal position.  The  bla<lder  has  bcTn  emptied  of  urine.  The 
tip  of  the  meatus  calibrator  is  passed  mto  the  urethra  and  the 
size  of  the  undilated  meatus  Ls  read  on  the  scale  of  the  calibrator. 
Suppose  it  reads  6  millimeters.  A  No.  10  cystoscope  may 
be  used  and  the  meatus  must  \yQ  dilated  a  little.  This  should  be 
done  by  gentle  pressure  on  the  conical  calibrator  and  twisting  it, 
care  being  taken  that  the  lubrication  is  ample.  If  the  tissues 
about  the  meatus  prove  to  l)e  rigid  it  is  wise  not  to  make  all  of  the 
dilatation  at  one  sitting,  for  the  patient's  confidence  will  be  lost  if 
she  is  hurt  too  much.  If  there  is  a  stricture  of  the  urethra  it  must 
be  dilated  with  the  double-c^nded  steel  dilators,  and  the  dilatation 
should  occupy  s(»veral  sittings.  The  meatus  b(*mg  stretched  to 
10  millimeters  without  laceration  or  excessive  pain  to  the  patient, 
the  next  step  is  the  cocainization  of  the  urethra.  Sometimes,  if 
the  meatus  is  sensitive,  it  will  be  found  lx»st  to  use  the  cocaine 
before  dilating  the  m(»atus. 

To  cocainize  the  urethra  w(»tthe  terminal  two  inches  of  the  uterine 
applicator  and  wrap  it,  using  a  sterile  rubber  glove  to  handle  the 
cotton,  with  a  thin  lay(T  of  absorlx^nt  cotton  so  that  the  diameter 
of  the  wrapped  applicator  is  about  three-sixteenths  of  an  inch 
(4  millimeters).  Soak  this  in  stc^rile  ten-per-cent  cocaine  solution 
gently  ins(»rt  the  applicator  into  thi»  un^thra,  hold  the  cotton  at 
the  meatus  with  two  fingers  whik*  the  ap[)licator  is  withdrawn  with 
the  other  hand,  k»aving  the  cotton  in  the  urethra. 

It  is  w(»ll  not  to  pass  the  tip  of  the  applicator  beyond  the  neck 
of  the  bladder,  because  if  tliL^  is  done  ardor  urinse  is  likely  to  be 
evoked  and,  th(»  cotton  acting  as  a  wick,  urine  will  drip  from  the 
end  projecting  from  th(^  meatus,  thus  diluting  the  cocaine  and 
soiling  the  patient's  clothing  while  she  is  bcnng  put  in  the  knee- 
chest  position  for  tin*  cystoscopy. 

A  kne(ychest  position,  modified  from  that  describcnl  on  page 
56,  is  the  one  commonly  employed  for  cystoscopic  examinations. 


DIRECT  C\^STOSCOPy 


111 


In  this  case  the  thighs  are  not  vertical  as  in  the  correct  knee- 
chest  position,  the  knees  being  nearer  the  chest.  In  very  stout 
imtients  and  in  certain  operative  cases  the  raiseil  pelvis  position 
(page  oS)  is  eniployeii.  By  the  time  all  the  instruments  are 
reacly»  the  room  is  darken*^!,  antl  the  patient  is  well  settled  in  the 
correct  knee^'hest  tx)sition  (four  or  five  minutes),  the  cocaine 
shoulil  have  produ<^ed  sufficient  anesthesia  of  the  urethra  to  permit 
us  to  procetHl  with  the  cystoseo])y. 

Ai-tificiai  hght  is  necessary  for  eysto*^'0j>y.  An  electric  light, 
gas  light,  or  a  kerosene  lamp  is  to  l>e  chosen  in  tlie  onler  named. 
ITie    ordinaiy  sLxtfH'n-candle-power  electric  lamji  is  sufficient,  a 


\\i 


Fm.  53. 


-ModififNi  luiee-chi'st  Position  Usctl  in  CyBloaoopy, 

Buttorktt  II)   rbu  MoiHfiwl   Position. 


£r.  la  posiUon  of 


thirty-two-canrlli^power  lamp  with  a  tin  reflector  is  better.  An 
argand  burner  nmkes  the  Ix^*^  ga.s  light,  but  a  Welslmch  light  is 
good.  A  kerosene  lamp  nmst  have  a  circular  burner  so  as  to  give 
a  large  flame.  .Vny  lamp  should  have  the  shortest  possible  stand  so 
that  the  source  of  light  may  be  a^  near  to  the  patient's  sacrum  as 
I*j«st5ible.  hi  ordcT  lliat  the  angle  formed  at  the  mirror  on  the  opera- 
tor*s  foreheail  between  the  rays  from  the  source  of  hght  and  the 
rtflected  raj's  going  into  the  bladder  may  be  as  acute  as  possible. 
It  should  be  rememlMT<*<l  that  the  electric  light,  if  held  near  the 
uncov€*re<l  skin  for  any  lengtli  of  time,  will  cause  a  serious  bnni. 
If  the  patient  is  anesthctizcni  this  is  a  vcrj^  imjiortant  fact  to  \year 
in  mind. 


DIRECT  (TSTl^SCOPY 


113 


Any  fomi  of  illumination  iiitrodu(*etl  into  the  bladder  oliHtruets 
the  vieWj  the  wros  for  the  lanij)  cutting  off  a  part  of  the  lumen  of 
the  urethra,  Ix^ides  the  n.-^k  of  buramg  the  bladder  by  the  heat 
^generate*!  by  th**  lamp. 

All  being  in  readiness,  the  pleilget  of  cocaine-soaked  cotton  is 
remove*]  fmm  the  uretlira  and  a  welMubricated  No.  10  eystoseoi>c 
with  its  obturator  in  place  is  passed  into  the  urethra  an*l  blarlder 
If  «ir  does  not  enter  the  vagiua  it  in  well  to  open  the  introitus 


ir" 


i^i: 


k 


J^JSs^ 


^^. 


/ 


b\\ 


^^*^. 


v^^ 


I  FiO.  56. — Suction  Apparatus  in  Uae  for  Hemoving  Urine  from  Bladder     (Kelly.) 


\'a^ie  with  one  finger.  If  the  bladdrr  <!oi»s  not  balloon  at  onee, 
the  silver  catheter,  previously  ck-aneil  and  lubricated,  is  passed 
through  the  sphincter  ani,  thus  lettmg  air  udo  the  rectum,  and 
pc*rniitting  the  trigone  of  the  bladder  to  come  more  into  view 
through  the  cystoscope. 

Tlie  operator  sits  on  a  high  stool  and  looks  through  the  cysto- 
itcope,  which  should  be  jiraetically  horizontal  if  the  patient  is  in  the 
proper  position. 


114       THE  URETHRA,  BLADDER,  AND  URETERS 

If  urine  has  collected  in  the  superior  portion  of  the  bladder,  or 
if  it  collects  during  the  examination,  it  is  to  be  removed  by  the 
bent  tube  introduced  through  the  cystoscope,  suction  bemg  applied 
by  means  of  the  bulb  and  rubber  tube  attached  to  the  tube  in  the 
bladder.  The  greatest  care  should  be  exercised  to  have  the  bulb 
and  tubes  sterile,  so  that  infection  may  not  be  introduced,  and  to 
this  end  the  bulb  should  be  squeezed  and  held  collapsed  while  the 
end  of  the  tube  is  rinsed  in  sterile  water  before  it  is  introduced. 
A  modified  chemical-laboratory  wash-bottle  may  be  used  for  re- 
moving the  urine,  as  shown  in  figure  55. 

In  cystoscopy  with  the  patient  in  the  elevated-pelvis  position 
the  collection  of  urine  at  the  fundus  of  the  bladder  is  much  more 
troublesome  than  it  is  when  the  patient  is  in  the  knee-chest  position, 
for  in  the  latter  position  the  urine  falls  into  the  capacious  superior 
part  of  the  bladder  behind  the  pubes. 

The  different  landmarks  of  the  bladder  are  sought  for,  the 
ureteral  orifices  inspected.  Bits  of  tissue  may  be  removed  from 
ulcerated  areas  or  new  growths  with  the  alligator  forceps;  cultures 
taken,  or  the  ureters  catheterized.     Of  the  last,  more  shortly. 

A  culture  is  taken  by  bending  the  handle  of  a  sterile  cotton- 
tipped  uterine  applicator  so  that  the  applicator  will  pass  through 
the  cystoscope  without  obstructing  the  view.  After  the  desired 
area  in  the  bladder  has  been  swabbed  with  the  cotton,  the  latter 
is  drawn  over  the  surface  of  the  slant  agar  tube,  hydrocele  agar 
being  used  when  gonococcus  infection  is  suspected. 

To  find  the  ureteral  orifices  first  determine  the  situation  of  the 
internal  opening  of  the  urethra.  This  is  done  by  noting  the  point 
at  which  the  urethral  mucous  membrane  begins  to  roll  into  the 
lumen  of  the  speculum.  The  trigone,  which  is  more  injected  than 
the  rest  of  the  bladder,  is  the  space  between  the  two  ureteral 
orifices  and  the  openhig  of  the  urethra.  It  is  small;  therefore,  the 
ureteral  orifice  is  near  at  hand.  If  a  V  is  marked  on  the  external 
upper  part  of  the  cylinder  of  the  cystoscope,  with  its  point  toward 
the  bladder  end  and  the  sides  of  the  V  separated  by  an  angle  of 
thirty  degrees,  the  ureteral  orifice  on  one  side  may  be  found  by 
bringing  an  arm  of  the  V  parallel  with  the  axis  of  the  urethra,  when 
the  cystoscope  will  point  toward  the  ureteral  orifice  on  the  same 
side.  The  ureteral  opening  is  a  little  slit  situated  on  the  mons 
ureteris,  a  slight  eminence. 


CATHETERIZATION  OF  THE  URETERS 


115 


Inspoc'tioii  of  the  urethra,  endoscopy,  is  jTractised  a.^  the  cystfv 
scope  ii*  vvithtlrawii.  The  neck  of  the  bla^lder  is  i*ecognized  as  the 
first  i>art.  of  the  roUing-in  rini  of  mucoys  niembmne  coming  into  the 
hinien  of  the  cystosco|>e  at^  the  latter  is  bfnng  withih-awn.  Then  in 
succession  follow  the  diffen^nt  portions  of  the  urethra,  the  meatus 
being  iaM.  After  the  patient  has  been  restored  to  the  florsal 
position  following  cystoscopy  in  the  knee-chest  position,  it  is 
ess^'ntial  to  pass  the  silver  catheter  into  {lie  bladder  to  let  out  the 
air  which  has  accumulated.  If  the  physician  rernernbers  to  do 
tWs  the  patient  will  \ye  spared  the  ardor  urinfc  and  the  discomff»rt 
which  attentl  a  distenfled  bladder*  OccasioTially  the  endoscope 
of  Skene  or  the  urethral  bi^'alve  speculum  recommenrled  by  liiru 
are  of  grt^at  service  in  viewing  the  interior  of  the  urethra,  esjjecially 
in  investigating  new  growttis.  These  instruments  have  not  been 
include*!  in  the  list  of  instruments  necessary  for  the  investigation 
of  the  urethra,  because  the  cystoscoi>e  generally  answei's  eveiy 
pur|)06e  of  diagnosis,  and  simplicity  of  technicjue  is  aimed  at  in 
this  Ix)ok. 

CatheterizatioQ  of  the  Ureters,— If  the  bladder  is  the  seat  of 
infective  inflammation  the  physician  should  debate  seriously  the 
ailvisability  of  eatheterizing  the  urett*rs,  more  especially  if  he  has 
rt^ason  to  bcdieve  that  the  ureters  are  not  infected.  If  it  is  a 
question  of  unilateral  gonm'tX'cus  or  tulx^rculous  infection  of  kidney 
and  ureter  with  erdargtnl  kidney  and  thickened  ureter,  the  diseased 
urettT  shouli]  U*  catheterized,  the  healthy  ureter  should  not  b* 
cathet4.Tize<l,  IxTause  of  the  great  danger  of  introducing  septic 
matter  into  a  sound  ureter,  the  problem  tjeing  similar  to  that  of 
[lapsing  the  catheter  through  the  neck  of  tlie  bladder  in  cases  of 
gonon'hra  of  the*  m*eihra,  or  of  introducing  instruments  l:)eyond  Ui«* 
internal  os  uteri  in  infections  of  tlie  vagina  and  cervical  canal. 
Nature  has  set  up  w^ell-defined  Imrriers  againvst  infection,  anrl  the 
physician  should  he  assured  of  good  results  to  follow  lx*fore  breaking 
I  hem  down. 

The  ureteral  orifices  arc  found  by  tiepressing  the  handle  of  the 
eysto«cope  and  carrying  it  to  one  sitlc*  while  the  tip  is  raised  toward 
the  patient  s  sacnini.  The  dimensions  of  the  trigone  are  Ixmie  in 
mind  and  the  orifice  shows  in  tlie  j)roper  ])lacr  as  a  minute  ojiening 
from  witich  a  drop  of  urine  spurts  every  few  moments*  The 
rapidity  of  the  flow  of  uiiuc  is  dependent  on  the  activity  of  the 


116       THE  URETHRA,  BLADDER,  AND  URETERS 

kidney,  on  the  amount  of  fluids  the  patient  has  recently  taken, 
and  on  the  state  of  the  nen'ous  sj-stem.  Sometimes  it  is  advisable 
to  regulate  these  factors  before  proceeding  with  a  cystoscopy.  Both 
orifices  should  be  found  before  a  catheter  is  passed,  because  in 
some  cases  the  orifice  may  be  displaced  by  uterine  malpositions,  by 
pelvic  inflammation,  or  by  other  abnormalities  of  the  pelvic  organs. 

The  ureteral  orifice  being  found,  the  ureteral  searcher  is  passed 
into  it  to  make  sure  that  it  is  the  ureter  and  not  a  pocket  in  the 
mucous  membrane.  Then  the  catheter  is  passed  and  the  cj-stoscope 
is  withdrawn  over  it.  The  cystoscope  ^ith  its  obturator  in  place 
is  reintroduced  beside  the  catheter  and  the  opposite  ureteral  orifice 
is  found  and  catheterized  in  similar  fashion. 

Now  the  patient  is  gradually  lowered  into  the  dorsal  position, 
the  physician  guarding  the  ends  of  the  catheters  as  she  moves. 


Fig.  56. — Nitze's  Model  of  Ureter  Cystoscope  for  Catheterizing  Both  Ureters. 

The  sterile  two-ounce  bottles  collect  the  urine  from  each  ureter, 
the  amount  of  urine  and  the  time  of  flow  being  noted  on  each  bottle 
as  well  as  the  ureter  from  which  the  urine  came.  Great  care  is  to 
be  taken  to  mark  the  bottles  correctly,  and  to  this  end  it  is  best 
to  stick  a  gummed  label  on  each  bottle  before  the  catheterization, 
and  to  mark  the  bottles  at  once  after  they  are  used. 

In  exceptional  cases  something  may  be  learned  as  to  stone  in 
the  ureter  or  stricture  of  the  ureter  by  passing  ureteral  bougies. 
Wax-tipped  bougies  have  been  used  with  success  in  diagnosticating 
stone  in  the  kidney,  but  much  skill,  gained  by  long  experience  in 
this  field,  is  necessary  to  produce  results. 

Catheterization  of  the  ureters  with  the  patient  in  the  elevated- 
pelvis  position,  a  more  convenient  position  when  an  anesthetic 
is  used,  is  conducted  much  as  in  the  kn(»e-chest  position.  The 
light  is  h(»l(l  close  to  the  patient's  pulx^s  and  the  operator  stands 
looking  downward,  through  the  cystoscope  to  the  trigone.     When 


IXBTRKCT  CYRTOSCOPY 


117 


llie  oat  lift  el's  mv   in    phivo   the   patient's   pvlvU   Ls   lowered  to 
the  table. 

It  should  Ix^  remembererl  that  the  eystoseopic  appearances  and 
the  situation  u{  tlie  urctt^ml  orifiees  tire  alterinl 
by  iTialpositions  and  tumors  of  the  utrTu.-^  ami 
by  other  pehie  tuniorn.  For  uisf anee,  in  pro- 
lapse folds  a|»pi'ar  in  tlie  bladder  mucosa  after 
r(*|x)wsition  of  tJie  uterus  and  the  cystfX'ele. 

Indirect  Cystoscopy  with  Water-Distended 
Bladder, — The  instruments^  necessary  are: — a 
Nit  2e  cyhtoyieope  with  wire.s  and  electrie-light 
connection,  a  current  controller  and  source  of 
ek*ctricity,  wuch  as  the  strei^t  current  or  a 
storage  battery,  irrigating  bag  and  onc-per- 
cent  boric-aeid  solution,  urethral  cahbrator, 
urethral  catheter,  uterine  applicator,  absorf>- 
ent  cotton,  antl  roraine.  The  bladder  .should 
have  a  capacity  of  at  least  five  omices  and 
the  Huid  should  be  clear;  if  it  is  not,  an  irrigat- 
ing cystost'ope  must  be  employed.  The  pa- 
tient is  in  the  dorsal  position ;  the  meatus  urin- 
arius  is  dilated  with  the  m^etliral  calibrator 
(cocaine  being  used  if  necessary  as  described 
in  direct  cystoscopy,  page  110)  until  it  will 
admit  a  No.  25  French  soiuid,  the  usual  diarneter  of  most  eysto- 
scopes.  If  there  is  a  stricture  of  the  uretlira  it  must  be  dilated. 
No  bleeding  should  aecornpnny  the  intrmliiction  of  the  cystoscope, 
hecau^  it  will  spoil  the  view^  in  the  blaiider.  Before  introtluring 
the  eystoscope  fill  the  blatlder  with  boric-acid  solution  and  allow 
it  to  ran  out  until  tlie  water  is  clear,  then  from  five  to  seven 
ounces  are  injected  and  the  catheter  withdra^\Ti,  The  eystoscope 
15  connected  mth  the  source  of  light  and  the  lamp  tested.  Then 
the  current  is  turned  off  and  the  instniment  is  smeared  witli 
lubrichondrin  and  introduce<l,  care  being  taken  to  depress  the 
faandJe  as  the  curve  passes  the  neck  of  the  bladder. 

The  following  are  the  appearances  of  the  bladder  as  seen  through 
the  eystoscope  accortling  to  Casfx^r  (**A  Text-Book  of  Genito- 
urinary Diseases '').  The  normal  mucous  membrane  of  the  liladdfT 
varies  from  light  yellow  to  pink,  being  redder  at  the  base  than  in 


Fig.  57.  —  Current 
Controller  for  Ung  with 
Electric  C*ystoseope. 


118  THE  URETHRA,  BL-\DDER,  AND  I'RETERS 

other  parts.  In  the  course  of  a  prolongcxl  examination  urine  is 
poured  out  into  the  bladder  l)y  the  un»ters  and  the  color  of  the 
mucosa  becomes  redder  because  of  the  yellowness  of  the  medium 
through  which  it  is  sc^n,  also  if  the  brightness  of  the  light  dimin- 
ishes the  color  becomes  redder,  therefore  the  light  should  be  bright 

and  white.  The  delicate  ramifying 
blood-vessels,  especially  well  marked 
at  the  fundus,  are  similar  to  the 
vessels  sei»n  with  the  ophthalmoscope 
at  the  fundus  of  the  eye.  Bundles  of 
muscle  filx^rs,  parts  of  the  detrasor 
v(\^ica%  make  little  ridges  in  the  blad- 
der walls,  especially  in  the  superior 

T..  ro  r»,  jj  Tju  *  t  and  lateral  portions.  Exaggerations 
Fig.  58.— Bladder  Phantom  for  .  ,  ,  ,  ^^ 

Practising  Cystoscopy.  of  these  ridges  become  the  *' trabec- 

ular''  in  the  cases  of  hypertrophy  of 
these  muscles  when  increased  work  has  been  thrown  upon 
them,  as  in  stricture  of  the  urethra.  Between  the  trabecule 
may  be  diverticula,  which  look  like  deep  excavations  in  the  bladder 
wall.  A  shadow  will  cover  a  part  of  the  circular  field  of  vision  if 
the  cystoscope  is  withdrawn  from  the  middle  of  the  bladder.  This 
is  due  to  the  fact  that  a  part  of  the  prism  in  the  cystoscope  is 
covered  by  the  sphincter  vesicie  muscle.  Carrying  the  beak  of 
the  instrument  downward  brmgs  the  base  of  the  bladder  into  view, 
and  pushing  it  a  little  backward  and  to  one  side  brings  the  opposite 
ureteral  elevation  into  the  fiekl.  If  the  ureteral  eminence  is 
watched  for  a  little  time  it  will  Ix^  seen  to  swell  up  suddenly,  make 
a  con\ailsivc  movement,  and  at  the  same  time  an  eddy  will  be 
observed  in  the  bladder  fluid.  This  is  the  periodic  discharge  of 
urine.  If  the  urine  is  discolored  the  bladder  fluid  will  have  to  be 
renewcMl  either  l)y  irrigation  tlu-ough  a  catheter  or  an  irrigating 
cystoscope.  Often  the  urine  from  one  ureter  will  be  clear  and  from 
the  other  cloudy. 

This  form  of  cystoscopy,  like  the  direct  form,  should  not  be  used 
in  the  presence  of  acute  inflammation  of  the  bladder  and  it  can 
not  be  employed  in  the  case  of  a  contracted  bladder.  In  chronic 
catarrhal  cystitis  the  mucous  membrane  appears  to  be  puffy, 
velvety,  and  red,  and  is  coated  with  secretion.  The  vascular 
network  is  no  longer  visible,  the  surface  of  the  bladder  looking 


THR  OMDCYSTaSCOPY 


119 


cloudy  and  dull     Seak«  ajid  flakes  cif  secretion  are  foiintl  floating 

fri*e  in  the  fluid  or  on  the  bladder  wall     TulxTeuIous  cystitis 

««hows  noilules  surrounded  by  a  red  border  situated  mostly  on  the 

flour  of  the  bla<Mer,  and  in  advanced  case\^  distinct  ulcers  are 

visible.    Tumors  of  the  bladtler  give  especially  good  pictures  with 

Jihia  form  of  eysloscope  and  so  tlo  vesical  ealcyli.     Fon/ign  Ixxlies 

re-an  l>c  distinguished  and  their  size  and  shape  determined,  and  a 

ureteral  catheter,  introduced  into  a  ureter,  may  Ix*  seen  disajjpear- 

ling  through  the  ureteral  orifice  and  throwing  a  shallow  below  it  on 

the  l)ase  of  the  bladder. 

To  those  who  are  interested  in  this  form  of  cystoscopy  the 
following  books  are  recommendrn! :  **  Die  rystoskopie  beira  Wcibe/ ' 
Dr.  Ricliard  Knorr;   'Miandbnch  der   (Rystoskopie/'  Dr.    Leopold 

,  i  nat  Cr. 


Fio,  5©.^Luya  tlnne  Separator  It  T>i\n<lc»»  the  RliulfJf^r  into  Halves  hy 
a  Hemovable  Diaphragm  and  the  Urine  from  Eacli  Half  h  Ckjllected  liy  a 
8t^imil4;  Tube. 

Cft8piT;  '*Handatla.sder  Cystoskopie/'  Dr.  OttoKneise;  *^\  Hand- 
lx>ok  of  Clinieal  Cyjstoseo|>y/*  E.  Hurry  Fenwick. 

Cbiomocystoscopy. — CTironioeystost*opy  is  a  metho4l  of  investigat- 
ing the  functional  capacity  of  each  kidney  that  has  Ijeen  used 
abroad  for  the  past  s^ix  }*ears  with  success.  It  con.'i^ist.s  of  cy»sto- 
scopy  with  water-filleil  l>ladder.  Fifteen  minims  of  a  five-per-eent 
aqueous  Hotution  of  methylene  blue  are  injectetl  into  the  buttock. 
In  five  minuter,  more  or  les.s  in  individual  cases?,  the  urine  is  rendered 
blue  and  can  be  seen  tlirough  the  cystosco|>c  spurting  from  the 
mouths  of  the  ureters.  The  urine*  from  the  two  uretei*s  is  coni- 
l>ared  as  regards  the  following  points: — The  interval  before  its 
appearance,  the  intensity  of  the  color,  the  number  of  jets  to  the 
niinute,  and  the  force  of  the  jet.  If  one  ureter  eliminates  dark 
blue  urine  while  there  is  no  trace  of  stain  in  the  urine  from  the  other 


120  THE  URETHR-V  BLADDER.  AND  URETERS 

kidnw,  there  may  be  ohstniction  by  a  sUne  in  the  ureter  gi\Tng 
colorlffss  urine,  or  compresaion  of  this  ureter  so  that  the  passage  of 
the  urine  is  delayed,  or  such  extensive  destruction  of  the  kidney 
tissue  on  this  side  that  the  stain  has  not  been  excreted.  The 
methor]  Ls  said  to  obviate  the  necessity  for  ureteral  catheterization 
in  many  ca.s'-s  and  to  give  a  reliable  indication  of  the  functional 
cafiacity  of  each  kidney,  besides  afifording  a  means  of  finding  an 
otherwL*5e  hidden  ureteral  orifice. 


CHAPTER  IX 

THE  INVESTIGATION  OF  THE  RECTUM" 

Inspeelion  of  the  ftnns,  p.  1^1.  Anakmiy  of  iJie  rt^dinn,  p.  HI,  Diplal 
examination,  p.  H3.  ProclQsco|>\\  p,  1^4,  Stretching  the  sfiliincler  and 
i^ieculiUD  examinaUoi]  af  the  rectiiQi  with  an  anestbeiic,  p,  Htl. 

The  frequent  associatinn  of  rectal  and  gjuceological  affeetions 
makes  the  diagnosis  of  the  fonner  important,  also  symptoois  in 
g>'neeologicaI  disease  are  so  often  referred  to  the  rectum  that  it 
becomes  most  necessary  to  eliminate  rectal  tUsease. 

Of  course  the  rectum  shoiUd  be  empty  before  an  examination 
is  made,  an  enema  being  given  if  there  is  any  <loubt  on  this  point, 
and  it  should  be  given  always  in  cases  where  the  rectum  is  to  be 
investigateil  with  the  (jroctoscope.  In  those  eases  in  which  there 
is  protrusion  of  the  bowel  only  at  stool,  the  patient  should  go  to 
the  elos€'t  Ix^fore  the  examination, 

Inq>ectioa  of  the  Anus, — The  best  position  for  both  visual  and 
distal  examination  is  the  Sims  position.  Inspection  of  the  anus 
may  show  external  hemorrhoids,  and  internal  hemorrhoids  after 
the  patient  has  just  been  to  the  chisct,  external  fistuUe,  ulcerations, 
pin  worms,  al>sce8s,  fissure,  ainl  skin  diseases,  such  as  eczema  and 
venereal  warts.  If  the  hutto(*ks  are  separated  by  the  hands  and 
the  patient  bears  down,  a  fissure  may  bo  brought  into  vicnv. 

Some  points  in  the  diagnosis  have  been  obtained  alrcaviy  from  the 
vaginal  examination.  Tumors  can  be  ruled  out  by  the  vagina] 
touch.  The  sphincter  aiii  is  jiow  everted  by  a  finger  in  the  vagina 
presBing  the  rectal  wall  out  through  the  anus,  thus  affording  an 
Opportunity  for  study  and  a  search  for  hemorrhoids,  i)oIyj»i,  ulcera- 
tions, fissures,  or  fi^tulae.  This  procetiurc  can  not,  however,  be 
executed  in  virgins  with  unstretchrd  perinea,  a  reasonal>le  amount 
of  injurj'  or  elasticity  of  the  |)erineum  being  a  necessity. 

Before  taking  up  the  digital  examination  let  us  review  a  few  points 
to  the  anatomy  and  physiology  of  the  n*c*tura. 

Anatomy  of  the  Rectum. — The  rectum  is  aliout  eight  mehes  long, 
merguig  above  into  the  sigmoid  flexure  of  the  descending  colon  at 

121 


■ 


122  THE  IX^ESTIGATIOX  OF  THE  RECTUM 

the  left  sacra-iliac  articulation,  there  being  no  distinct  point  of  sepa- 
ration between  the  two.  The  upper  portion,  four  inches  long,  is 
almost  completely  surroundcnl  by  peritoneum.  The  peritoneum 
is  reflected  from  the  anterior  surface  of  the  middle  portion  or 
ampulla,  which  is  three  inches  long,  at  a  point  about  two 
and  a  quarter  inches  from  the  anus  to  pass  on  to  the  posterior 
wall  of  the  vagina.  As  the  anterior  and  posterior  walls  of  this 
part  of  the  rectum  are  in  apposition  when  it  is  not  distended 
by  feces  or  gases,  it  appears  in  sections  as  a  transA'crse  slit. 
The  third  portion,  or  anal  canal,  an  inch  long,  is  the  part 
surrounded  by  the  internal  sphincter  above  and  external 
sphincter  below,  and  supported  by  the  levatores  ani  muscles. 
When  empty  this  part  is  seen  in  a  vertical  median  section  as  a 
longitudinal  slit.  It  is  to  be  borne  in  mhid  that  the  long  axis  of 
the  canal  of  the  anus  is  nearly  horizontal  when  the  patient  is  in  the 
erect  posture  and  is  at  approximately  a  right  angle  to  the  long  axis 
of  the  two  upper  portions  of  the  rectum, — ^therefore  the  anus  dis- 
charges the  fluid  fecal  contents  not  downward  in  the  axis  of  the 
body,  but  backward.  The  soiled  state  of  the  rear  boards  of  a  coun- 
try pri\'y  bears  testimony  to  this  fact  in  anatomy.  When  solid 
fecal  masses  arc  passed  the  anal  canal  is  taken  up  much  as  the  cervix 
uteri  is  taken  up  during  labor,  and  the  feces  are  extruded  dowTi- 
ward.  This  obliquity  of  the  anal  canal  to  the  main  lumen  of  the 
rectum  lessens  the  din^'t  strain  on  the  sphincter  made  by  accu- 
mulations of  fecal  matter  and  gases. 

The  rectum  is  composed  of  four  coats, — serous,  muscular,  areolar, 
and  mucous.  It  is  similar  in  structure  to  the  rest  of  the  large  in- 
testine, except  that  the  semilunar  folds  of  the  mucous  membrane 
to  be  found  higher  up  in  the  bowel  are  here  strongly  developed,  so 
that  they  form  shelves  projecting  into  the  lumen  of  the  gut.  These 
shelves  or  valves  (valves  of  Houston)  are  generally  three  in  number, 
two  high  up,  are  on  the  sides  of  the  rectum,  a  third  and  the  largest, 
is  in  front  opposite  the  base  of  the  bladder.  When  a  fourth  is 
present  it  is  in  the  ampulla  on  the  posterior  wall  about  an  inch 
above  the  anus.  These  valves  are  disposed  alternately.  WTien 
the  rectum  is  empty  they  overlap  each  other  so  that  it  is  difficult  to 
pass  a  bougie  or  other  foreign  Ixxly  by  them.  Their  function  is 
probably  to  support  the  weight  of  fecal  matter  and  prevent  it  from 
impinging  on  the  anus  where  its  presence  is  sure  to  excite  a  desire 


DIGITAL  EXAMINATION 


123 


for  defoeation*  Just  aliove  xlw  hitemal  sjjhineter  the  mucous 
membrane  is  thrown  into  i\mv  or  fmir  longituciirial  folds  on  each 
side,  The^*  are  known  as  the  columns  of  Morgagni.  Between 
them  are  little  jjockets,  or  valves. 

The  vesi^ls  of  the  rectum  lie  in  the  loose  areolar  tissue  Ix^tween 
the  muscular  and  mucous  coats,  and,  receiving  no  support  from  the 
mascles,  varicosity  is  favored.  Moreover^  t!ie  veins  ]jien*i>  tiie 
nmf^eular  coat,  run  ^superficially  in  a  longitudinal  dircM^tion,  and 
are  apt  to  lye  constricted  when  the  muscle  contmets;  also  there  are 
no  valves  in  the  superior  hemorrhoidal  veins^  and  hardened  fecc*s 
are  likely  to  press  on  them  and  stioke  the  Ijlood  downward,  away 
from  the  heart.  The  mucous  membrane  is  thick  and  loosely  con- 
nected to  the  muscular  coat  Ix^neath,  thus  favormg  prolapse, 


Fio.  GO. — Short  Proetoscnpe. 


illy  in  the  child,  where  the  rectum  is  straighter  than  in  the 


I 


The  reflex  contractions  of  the  sphincter  prevent  healing  of  a 
ure  and  are  a  i?ource  of  pain.     They  als(t  iirevent  an  ist-hio-rectal 
itecesa  from  closing  and  convert  it  into  a  fistula.     Because  over- 
developtnl  by  its  acti\'ity  in  such  cases,  the  sphincter  is  cspt*cially 
ig;  therefore  it  nmeit.  be  thoroughly  stretchcxl  to  the  point  of 
nporar}*  paralysis  b<^fore  any  o}>erative  procedure  can  Ix^  under- 
taki.'Ti  with  tlie  hojw  of  a  successful  outcome. 

Digital  Examination*— I1i»*  well-anoint rI  left  forefinger  is  passed 
into  the  anus,  the  direction  Ix^ing  first  forward  toward  the  vagma 
and  ihtTi  l>ackwanl.  If  the  patient  bt*ars  down  as  the  tip  of  the 
,gf>r  |>aA^«es  througli  the  anus,  the  spIiiiK'ter  is  i-elaxed  and  the 
ana]  eanal  is  «traightene^I.  Thus  the  discomfort  is  lessened  while 
the  finger  is  introduce<l  gradually  with  a  boring  motion.    The  an- 


124  THE  INVESTIGATION  OF  THE  RECTUM 

tenor  and  side-walls  of  the  ampulla  are  palpated.  A  lesion  on  the 
anterior  wall  is  felt  between  the  left  forefinger  in  the  rectum  and 
the  right  forefinger  in  the  vagina.  The  strength  of  the  sphincter 
ani  is  estimated,  spasm,  due  to  long-continued  irritation,  areas  of 
induration,  ulceration,  or  narrowing  of  the  caliber  of  the  gut,  and 
the  presence  of  tumors  are  determined.  A  general  smoothness  and 
absence  of  folds  indicates  atony. 

The  right  foi-efinger,  in  like  manner,  is  used  to  palpate  the 
posterior  wall  of  the  ampulla.  The  presence  of  internal  piles  is 
very  hard  to  diagnosticate  by  touch.  The  proctoscope  must  be 
used  for  these.  In  making  the  digital  examination  it  is  well  to 
pass  the  unused  fingers  of  the  examining  hand  between  the  nates, 
or  over  the  vulva  and  the  thumb  beside  the  vulva  or  between  the 


Fig.  61. — Long  Proctoscope. 

nates,  for  in  this  way  a  greater  distance  can  be  reached  in  the 
rectum  than  by  shutting  the  unused  fingers  on  the  palm  of  the 
hand.  If,  after  the  digital  examination,  the  diagnosis  is  still  in 
doubt,  the  Kelly  proctoscojx*  should  be  used. 

Proctoscopy. — ^A  good  light,  preferably  an  electric  light  and 
a  head  mirror,  are  necessan^  just  as  in  cystoscopy.  The  patient  is 
put  in  the  knee-chest  position.  Something  as  to  the  condition  of 
the  anal  canal  may  be  leameil  by  the  use  of  the  smallest-size  Sims 
vaginal  speculum  in  the  anus  and  some  physicians  report  good 
results  with  it.  Personally,  I  have  not  found  it  valuable  as  a 
means  of  diagnosis  unless  the  sphincter  has  been  first  stret<;hed. 
The  Sims  rectal  speculum  is  adapted  only  for  use  with  the  patient 
anesthetized. 

Two  proctoscopes  are  sufficient  for  diagnostic  purposes.     The 
shorter  one,  tliree  inches  (7.5  centimeters)  long  by  seven-eighths 


PROCTOSCOPY 


125 


and  a 


inch  (2,3  centimeters)  in  diameter,  is  passed  first.  It  is  thoroughly 
anointed  and  introduced  slowly  wliile  the  ijatient  bears  down. 
Thv  phj^ician  keeps  in  mind  the  direction  of  the  anal  canal  and  the 
rwtuin  proper;  the  tii*  of  thv  prrM:»tosc<>ije  with  its  obturator  in 
place  is  pointeil  first  downward  toward  the  pubcs,  then  inwani  in 
the  axis  of  the  botly  after  the  sphincter  has  fx»en  passed,  and  then 
upwartl  toward  the  sacrum,  RcinemlKT  the  situation  nf  the 
valves  of  the  rectum  ami  work  the  tip  of  the  proctoscope  by  them 
gradually.  Removing  the  obtm-ator  air  rushes  in,  balloons  the 
rectum,  and  permits  a  ^iew  of  the  lower  part  of  this  organ.     The 

[alligator  forceps  are  useful  to  remove  bits  of  feca!  matter  or  to 
IPfcipe  away  secretion  with  cotton  pledgets,  or  to  obtain  tissue  for 
microecopic  examination.  As  the  proctoscope  is  withdrawn  the 
internal  and  external  sphincters  arc  inspectefl  as  they  roll  into  the 
himen  of  the  proc^toscoiH:*,  The  loii^rT  proctoscope,  five 
^B  Fig.  62. — Long  Alligator  Forceps. 

half  inches  (14  centimeters)  long  by  seven-eighths  inch  (2.3  centi- 
meters) in  diameter,  is  of  value  to  inspect  the  upi)er  rectum.  The 
sigmoidodcope  is  a  dangerous  instrument,  for  although  by  its  use, 
in  favorable  cases,  a  glimpse  of  the  sigmoid  may  be  obtained ,  it 
b  likely  to  injure  tlie  bowel. 

In  introducing  the  longer  proctoscope  it  is  adWsable  to  remove 
the  obturator  after  the  spliincter  has  been  passed  and  to  carry  the 
instrument  higher  in  the  ret^tum  by  sight.  The  semilunar  valves 
caa  be  seen  and  avoided  by  the  advancing  edge  of  the  prwtoscope. 
Remember  that  the  empty  re<'tum  m  normally  contracted — that 
is  to  say,  its  walls  are  in  ai>position— therefore^  this  state  must 
not  be  mistaken  for  stricture.  The  air  sometimes  dm^s  not  separate 
the  wall*?  of  the  upper  rectum,  although  it  dr>f*s  those  of  the  ami>ulla. 

The  mucous  membmrie  of  the  n-cUmi  is  studdtnl  by  l>ranching 
Is  and  the  openings  of  little  glands  may  b<*  seen.  Inflamma- 
13S  marked  by  a  diffuse  velvety  injecteil  api>earancc  of  the 


126 


THE  INVESTIGATION  OF  THE  RECTUM 


mucosa,  together  with  the  disappearance  of  the  normal  branching 
vessels;  ulcerations  arc  easily  distinguished,  polypi  may  be  seen 
hanging  from  the  rectal  wall,  or  the  bleeding  surface  of  a  carcmoma 
may  obstruct  the  lumen  of  the  proctoscope.  If  there  is  stricture 
of  the  bowel  because  of  syphilis,  or  cancer,  a  smaller  proctoscope 
should  be  used.  A  large-sized  Kelly  cystoscope  will  often  serve 
instead  of  a  proctoscope  in  such  cases,  also  in  the  examination  of 
the  rectum  in  children. 

Stretching  the  Sphincter  and  Speculum  Examination  of  the  Rectum. 
In  exceptional  cases  it  is  necessary  to  give  an  anesthetic  in  order 
to  make  a  complete  diagnosis  of  rectal  disease.  In  such  an  event, 
after  the  patient  is  thoroughly  anesthetized  she  is  placed  in  the 


Fig.  63. — Sims  Rectal  Speculum. 

Sims  position ;  the  operator  anoints  lx)th  thumbs  and  inserts  them 
through  the  anus.  By  means  of  the  fingers  grasping  both  buttocks 
gt^ntlc  but  firm  traction  is  made  on  the  sphincter  ani.  A  good  deal 
of  time  should  be  devoted  to  the  stretching  of  the  sphincter,  some 
fifteen  minutes.  Rapid  and  forcible  stretching  is  very  apt  to 
result  in  rupture  of  the  muscle  followed  by  partial  or  complete 
permanent  incontinence  of  feces  or  in  fissure  of  the  mucous 
membrane.  Thorough  stretching  of  the  sphincter  is  an  essential 
for  any  instrumentation  of  the  rectum  except  proctoscopy.  After 
the  preliminary  stretching  the  sphincter  muscle  is  fixed  between  the 
thumb  and  forefinger  of  the  left  hand  and  successive  portions  of 
its  periphery  are  stretched  by  the  thumb  and  forefinger  of  the  right 
hand.  The  Sims  rectal  spi^culum  is  pa'<s(Ml  and  light  is  reflected 
into  the  rectum  by  the  head  mirror,  the  alligator  forceps  and  pled- 
gets of  cotton  being  used  to  wipe  away  discharges  and  feces. 


(^IIAFrKR   X. 

THE  SIGNIFICANCE  OF  THE  CHIEF  SYMl^OMS  OF 
PELVIC  DISEASE. 


Dysnienorrliea.  p.  1^8:  Frequency,  p,  HH:  Menstrual  inolimena,  p. 
MH.  L  DysriieTiorrhea  a.^tKMalrd  with  fjelvir  Ifsions,  p.  1^1*:  Con|^iiital 
nialfonnalions,  ({etrojKisitiori  with  aiileHexion,  Pelvic  itiflamtiuiljoti*  Filjroitk, 
[p.  1^.  II.  Dysmenorrhea  where  no  [ii»lvic  leskm  can  be  found,  p.  ISO: 
Kc*urolic  dysmenorrhea,  Dysmetiorrhea  due  to  poor  general  health,  p,  130. 
Membranous  dysmenorrhea,  p.  1:50. 

Inlermenstrual  pain,  p.  ]^H:     Description,  p.  \M,     Etiohi^y*  p.  L'ilt. 

Menorrhagia  und  Metrorrhfigia,  p.  I'U:  L  Cori.slihitronal  eauj*es,  p.  !*?«>. 
11.  Loca.1  causes,  p.  V.io:  1.  The  palient  is  n  virj^iri,  p.  VM;  Tabic  of  meii- 
iirrhii^ia  and  metrorrhj^fia  in  virgins,  p.  IJi?;  ^i.  T\w  fiatient  i^  not  a  virgin 
and  (a)  has  never  been  jiregnant,  fi.  187,  (//)  has  fK-^^n  pregnant »  p.  138;  (r)  is 
pre^jtJit,  pJIi8;  Table  uf  nienorrhagia  and  metrorrhagia  in  married  wonjen, 

Amenorrhea,  p.  lS9i  L  Primary  amenorrhea,  p.  1:13:  Due  to  (a)  Failure 
gn>wfh,  j»,  ViM;  (6)  Atresia  of  ibe  hymen  or  at  the  vagina,  p.  110.  i, 
!ijndary  amenorrhea,  p.  141 :  Due  to  (a)  Pregnancy  and  lacfalion,  p,  141; 
\(b)  Atrophy  of  the  ovaries,  jj.  14 h  ('i  Constitutional  diseases,  f>.  141:  (*0 
Itxhausfion  and  s[i<K*k,  \k  14^;  (r)  Hetentian  of  menses  from  acquired  atresia 
i  of  the  genital  canal,  p.  14^, 

Leucorrhea,  p*  14JJ:  Character  of  the  di.s<^hHrge,  p.  143;  White  dis- 
cliarge,  p.  14.1;  Yellow  discharge,  p.  llSi  Watery  discharge,  p.  IHi  FeM 
iijcharge*  p,  144;  Bk»ody  distharge*  p,  144*  Occnrrefice  of  leucorrhca,  ]>. 
144:  Leticorrhen  in  childrtm.  |).  144:  I^euc-orrhea  in  virgins,  p.  14."i;  Ixnt- 
oorrhea  in   marrii.'<I  women,  p.  IWx:    I-je»ietirrhea  in  old  women,  p.  14tL 

Dyspitreunia,  p.  14*1:  I.  Psychical  can.ses.  p.  14ti.  ii.  Anatonjica! 
causes,  p.  140. 

Sterility,  p.  147:  Absalnte.  p,  147:  Secondary,  p.  117:  Facultailve,  p, 
147,  Sterility  in  the  nnile,  p.  148.  Sterility  in  wumen,  p.  148:  Age  as  a 
factor,  p.  148;  Other  factnrs.  p.  14J),  Auoniaties  and  iliseasesof  the  uterine 
origans*  p.  150;  Conditions  of  the  uteri  tie  organs  that  cause  interruption  of 
|>regiiiinc*3r%  p.  150,  Constitutional  dist*ascs  and  general  causes*  p.  151, 

V'esicjJ  syniptoms,  p.  151  :     L  Dystiria,  p.  15 1 ;  General  catises  and  local 

causes,   p.    15*?.     2,  Ttxj   frequent    urinutjon,   p.    15:*,     3.  Incontinence   of 

tirine.    Enuresis,  p.    154:     Local    causes,  p.    154:    (General  eau.ses,  p.   155; 

•focfuma!  enuresis*   p.    155.      4,  Ketention  of  urine.  Ischuria,  p.   155,     5, 

Suppression  of  urine.  Anuria,  p.  I5(k 

Rectal  svmptoniH,  p.  15ti:     Pain,  p,  156,     Ilemorrhnge,  p.  157.     Rectal 
Itdchargv-,  p.  157.     Fecal  aix-umulation,  p,  157,     DifFtcnIly  in  defecation,  p. 
~158.     Fratru2»iou  from  the  anus,  p.  158,     Character  of  the  feces,  p.  158, 

127 


128  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

Coccygodynia,  p.  159:  Etiology  and  pathology,  p.  159.  Symptoms,  p. 
159.     Diagnosis,  p.  160. 

Pruritus  vulvae,  p.  160.  Caused  by:  1.  Irritating  discharges  from  the 
vagina  or  bladder,  p.  160;  2.  Diseases  of  the  vulva,  p.  161;  3.  Neuroses, 
p.  161. 


DYSMENORRHEA 

The  term  dysmenorrhea  (from  ^w?,  difficult,  A*iyv,  month,  and 
i^ieiv^  to  flow)  signifies  painful  menstruation,  and  is  used  to 
define  suffering  of  whatever  kind  associated  with  the  performance 
of  the  function  of  menstruation.  In  spite  of  the  many  theories 
advanced  to  explain  the  occurrence  of  pain  accompanying,  preced- 
ing, or  following  the  monthly  flow,  we  are  still  ignorant  of  the  cause. 
Authorities  are  not  agreed  as  to  the  frequency  of  pain  among 
normal  women.  Theoretically  the  woman  should  be  conscious  of 
menstruation  only  by  the  discharge  of  blood  from  the  vulva;  as 
a  matter  of  fact  a  considerable  proportion  of  women  have  some  sort 
of  discomfort.  Marie  Tobler  (Monatsschr,  fur  Geburts,  und  Gyn., 
1905,  Vol.  XXII.,  p.  1)  investigated  this  question  in  the  case  of 
one  thousand  and  twenty  women  and  found  that  twenty-six  per 
cent  had  local  pain,  general  discomfort,  malaise,  weakness,  or 
mental  disturbance  at  menstruation.  Some  writers  place  the 
percentage  of  local  or  general  discomfort  as  high  as  sixty  or  seventy 
per  cent  of  all  women.  It  is  to  be  remembered,  however,  that 
most  of  the  data  come  from  investigators  who  have  to  do  with 
women  afflicted  with  uterine  disease  and  not  with  normal  women. 

Memtrual  molimina  are  the  local  and  general  disturbances  that 
are  supposed  to  be  normal  to  menstruation;  they  are: — ^a  certain 
amount  of  pain  in  the  pelvis  extending  through  the  back  and  thighs, 
also  nervous  depression,  resulting  in  lassitude,  headache,  nervous 
instability,  and  derangement  of  the  function  of  different  organs. 

Some  of  the  last  are:  eye  strain,  skin  eruptions — such  as  urticaria 
and  acne, — pains  in  the  joints,  and  loosening  of  the  sacro-iliac 
joint  in  the  case  of  sacro-iliac  disease,  and  various  sorts  of  "neu- 
ralgias.'' They  are  often  spoken  of  as  "reflex  symptoms.''  Ex- 
aggeration of  the  menstrual  molimina  constitutes  dysmenorrhea, 
although  the  term  is  more*  often  applied  to  the  actual  pain  which 
is  referred  to  the  pelvis  than  to  the  more  distant  manifestations. 

Dysmenorrhea  may  be  classified  as  of  two  sorts,  (1)  that  associ- 


DYSMENOnUHEA 


129 


atccl  with  (Ipfinite  dis*'oveml>Ie  loj^ions  of  the  uterine  organs,  iiwl 
(2)  that  in  which  no  abni>nnality  of  thc>sc  organs  can  be  deter- 
niined. 

1.  Dysmexohrhka  Associatkd  with  Pelvic  Lesions 


This  includes  clysTuenorrhea  nectirring  in  the  case  of  (1)  Con- 
genital nialforinatinns  of  t!u*  utfTiiit^  (Organs,  (2)  retroposition  with 
anteflexion,  (3)  ix^Ivie  inflammation,  and  (4)  fibroids. 

I*  Congenital   Malformation  of  the   Uterine  Organs. — A  woman 

'ha\ing  an  infantile  uterus  or  a  congenitally  anteilexc^.!  uterun  is 

apt  to  sidTer  with  dysmenorrhea,  so  also,  in  the  ea*se  of  atrt»sia  of 

the  vagina  or  of  the  uterus  wIktu  the  ovaries  are  at  the  same  time 

WeM  develoi>ed,  imin  recurring  at  regular  interv^als  is  apt  to  be  a 

^constant  symptom. 

2.  Retroposition  with  Anteflexion. — Dysmenorrhea  is  the  rule  witli 
JthU  affection,  especially  in  tlu*  case  of  the  unfruitful.     The  jmin 

in  thesf*  casen  generally  Iw^gins  with  the  ajipearanee  of  the  fhnv,  it 
Is  cramp-hke,  and  is  rr^lieve^l  after  the  flow  has  bcTOUit*  well  estal> 
|j-she<l.  Frequent  and  painful  micturition  is  often  associated  with 
^this  mali>osition,  whate\'er  the  cause  may  be. 

This  is  a  sort  of  uterus  in  which  the  s«>ealle<l  obstntciive  dyfsmen- 
orrhea  was  suppose**!  by  Marion  Sim>?  and  his  followers  to  occur. 
LThiis  theory  is  that  the  escape  of  the  menstrual  disrliarges  is  impf*ded 
^by  the  flexing  of  the  uterine  canal  Ijy  a  stenasis  either  of  the  internal 
or  the  external  os,  by  an  mtra-uterine  jwlyp  acting  like  a  Irnll- 
valve,  or  by  clots  of  blood.  At  the  present  time  the  best  authori- 
ties*  are  agrn'^l  t!iut  artual  (tbstnu'tion  seldom  exists. 

3.  Pelvic  Inflammation."  Pelvic  inflammation  includes  endomc^ 
tritis^  and  also  pelvic  peritonitis,  sal|>ingitis,  ovaritis,  and  a  eertain 

lount  of  cellulitis.     In  the  acute  stages  of  pelvic  inflanmiatioti 
Ivfrnienorrhea  is  a  fairly  common  sjinptoni — perhaps  in  from  a 
d  to  a  half  of  all  ca^^s.     In  the  chronic  stages  it  causes  uterine 
^ition  and  chronic  emlonietritis,  which  art*  more  directly 
ausativT  of  painful  menstruation.     The  \m\n  is  apt  to  antedate 
ftlie  lx*ginning  of  tin*  flow  ancl  lasts  thnnigh  the  entire  fM'riotl. 

4.  Fibroids. — Dysmenorrhea  is  a  fairly  constant  accompaniment 
of  submucous  and  intcTstitial  myomata.     It  is  rare  in  the  sut>- 

mtoneal  80rt»    The  size  of  the  tumor  bears  no  definite  relation 
9 


130  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

to  the  amount  of  the  pain  exfx^rieneed;  often  the  pain  is  most 
severe  in  the  case  of  vcTy  small  tumors.  The  pain  in  the  uterus 
itself  must  be  differentiated  from  the  more  or  less  constant  pain 
due  to  pressure  by  large  tumors  on  the  surrounding  nerves  in  the 
pelvis.  The  pain  in  the  uterus,  according  to  Kelly  and  CuUen 
(**Myomata  of  the  Uterus"),  is  most  severe  at,  or  just  before,  the 
menstrual  period.  The  pain  from  pressure  is  apt  to  be  in  the  legs 
and  feet  and  may  be  mistaken  for  rheumatism. 


II.    Dysmenorrhea   Where   no   PEL\ac    Lesion   Can    be 

Found 

Dysmenorrhea  often  exists  in  women  who,  apparently,  have 
perfectly  normal  uterine  organs.  In  this  event  the  painful  men- 
struation is  (1)  neurotic,  or  (2)  due  to  poor  general  health. 

1.  Neurotic  Dysmenorrhea. — Neurotic  dysmenorrhea  appears  to 
be  due  to  excessive  sensitiveness  of  the  endometrium.  The  uterine 
contractions  occurring  during  menstruation  cause  abnormal  pain, 
something  like  the  after-pains  of  labor.  The?  formation  of  clots  in 
the  uterine  cavity,  exciting  expulsive  contractions  and  pain,  has 
been  assumed  to  be  the  cause  in  some  cases,  but  there  are  no  facts 
to  substantiate  this  theory.  Dysmenorrhea  is  often  observed  in 
cases  of  neurasthenia  and  sometimes  in  patients  with  this  disease 
who  previously  had  not  had  painful  menses.  The  physician  is 
often  left  in  doubt  which  is  cause  and  which  effect  in  the  investiga- 
tion of  neurasthc^nia  and  dysmenorrhea. 

2.  Dysmenorrhea  Due  to  Poor  General  Health. — Dysmenorrhea  is 
observed  frequently  in  girls  undcT  tw(»nty  who  are  the  subjects  of 
anemia  or  chlorosis.  There  are  no  satisfactory  theories  among  the 
many  that  have  been  advancc^l  to  explain  this  association  of  men- 
strual suffering  with  these  two  diseas(\s. 

Membranous  Dysmenorrhea. — Meml)ranous  dysmenorrhea  is 
characterized  by  severe  cramp-like  pains  in  the  lower  abdomen 
and  back,  resembling  lalx)r  pains,  occurring  at  the  time  of  men- 
struation and  followed  by  the  expulsion  of  a  more  or  less  incomplete 
cast  of  the  cavity  of  the  corpus  uteri  in  the  shape  of  a  sac,  triangular 
in  form,  gray  in  color,  and  having  a  rough  surface.    AVhen  floated 


MEM  BRAN0U8  D YSM  ENORR  HEA 


131 


in  water  and  laid  oj>en,  the  interior  of  the  sac  is  smooth.  With 
the  aid  of  a  niagnifyiiig  gla^s  this  smooth  surface  is  seen  to  be 
s^tiddnl  with  minute  openings  which  represt*nt  the  mouths  of  the 
utricular  glands.  If  the  sac  is  n^asonaMy  comjilete— it  is  self  lorn 
entire— tile  openings  of  tlie  Fallopian  tulK\s  may  Ix^  distinguished 
in  the  upix^r  cohhts.  The  membrane  Ls  from  one  to  three  milli- 
meters thick  and  under  the  microsco|je  shows  much  the  apix^ar- 
ance  of  exudative  interstitial  en*lonietritis,  although  the  patho- 
logical characteristics  of  the  membrane  are  not  constant;  therefore 
membranous  dysmenorrhea  is  not  a  tlefinite  disease  but  a  condition 
which  exists  in  the*  presence  of  different  pathological  processes. 

The  etiolog^^  of  this  dist*ase  is  sluTnided  in  myste^^^  As  far  as 
known,  endometritis  precedes  niend>ranous  tlysnienorrhea  in  a 
large  propoilion  of  cases.  In  certain  castas  menstruation  is  normal 
and  regular  until  infection  occurs  following  abortioii  or  labor:  then 
membranous  dysmenorrht'a  develops  hi  the  coui*se  of  a  fi'W  months. 
In  another  class  of  cases,  many  of  them  l>eing  munarried  wonjen, 
nienstruation  is  nonnal  and  regular  anti  the  painful  menstruation 
with  the  expulsion  of  a  membrane  tlevelops  without  any  api>arent 
catise.  Following  the  ex|>ulsion  of  the  membrane  there  is  generally 
a  profuse*  flow  of  blooth 

In  making  a  diagnosis  of  meml>ranons  dysmenorrhea  we  must 
exclude  (a)  df^ndual  endometritis  and  {h)  exfiJiativt*  vaginitis. 

(a)  In  the  case  of  decidual  endometritis  there  is  a  history  of 
pregnancy,  also  some  of  the  signs  of  pregnancy  or  extra-uterine 

'pn^'gnancy  should  U*  jiresi^it  (see  Chaptt^rs  XXII  and  XIX). 
Ilemorrliage  following  the  ex|)ulsion  of  the  membrane,  or  parts  of 
it,  generally  last«  longer  and  is  more  profuse  than  is  the  case  with 
m*'mbranous  dysmenorrhea.  The  cast,  of  the  uterine  cax-ity  is 
larg«*r  ami  more  vascular  than  in  the  case  of  the  membrane  of  dys- 
menorrhea, anil  chorionic  villi  should  bi*  visible  when  the  specimen 
is  examined  under  the  niist"rosco|M^. 

(b)  Erfoliative  lyaginitis  may  accompany  membranous  dysmen- 
orrhea, the  exfoliation  of  thi*  vagina  Ijeiiig  a  pail,  apparently,  of 
the  same  pathological  process  which  causes  the  casting  off  of  the 
endometrium.  Such  an  association,  although  authoritativt'ly 
n.'fK>rt(-Hl,  must  be  considered  as  very  rare,  Kxfoliative  vaginitis 
occurring  as  a  result  of  inHammation  or  from  treathig  the  vagina 
with  frtrong  caustics,  such  as  nitrate  of  silver  (see  Chapter  XX,  page 


132  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

364),  is  a  not  uncommon  disease,  and  if  the  lining  mucosa  Is  thro\iTi 
off  at  the  time  of  a  menstruation  which  is  accompanieil  by  cramps, 
the  physician  must  be  able  to  distinguish  between  a  cast  from  the 
vagina  and  one  from  the  uterine  cavity. 

A  vaginal  cast  when  floated  in  water  does  not  present  a  tri- 
angular shape  and  no  tubal  openings  are  to  be  sei^n.  However,  as 
all  casts  are  often  exjK^lled  in  pieces,  these  features  may  be  absent 
in  both  cases.  On  examining  a  vaginal  cast  with  a  magnifying 
glass  it  will  be  s(»en  to  have  a  surface  that  is  relatively  rough  and 
there  are  no  ojx^nings  of  glands  in  it.  Microscopic  examination 
shows  it  to  be  made  up  of  stratified  vaginal  epithelium  and  the 
characteristic  glandular  structure  of  the  endometrium  is  absent. 


HfTERMENSTRUAL   PAIN 

Intermenstrual  pain,  or  "Mittelschmerz,''  is  the  name  given  to 
pain  similar  to  the  pain  of  dysmenorrhea,  occurring  on  a  definite 
date  lx»tween  two  menstrual  periods,  often  midway  between,  but 
not  always. 

This  affection  is  by  no  means  uncommon  and  every  gynecologist 
of  wide  experience  has  met  with  several  cases.  Dr.  H.  A.  Kelly 
(''Medical  G\Tiecology '')  has  collectcxl  sixty-four  easels  fi"om  his  own 
experience  and  the  litcTature,  and  I  will  sunnnarize  his  conclusions 
from  an  analysis  of  these  cases. 

As  a  rule  intermenstmal  pain  do(»s  not  begin  with  the  first 
menstmation,  but  is  generally  notcnl  during  the  period  of  full  sexual 
activity,  that  is,  between  the  years  of  twenty  and  thirty-five.  In 
a  majority  of  cases  it  is  ass(H*iatt»<l  with  sterility,  but  in  a  large 
propoi-tion  of  the  child-lK'aring  women  who  are  the  subjects  of  this 
pain,  pregnancy  scK^ms  to  stand  in  a  causal  reflation  to  the  inter- 
menstrual j)ain. 

Thn^e  cases  of  intermenstrual  pain  have  Ix^en  reported  in  which, 
pregnancy  supervening,  the  pain  ceasc^l  entin^ly  during  pregnancy 
and  during  lactation,  only  to  retui-n  on  the*  reestablishment  of 
menstruation. 

The  pain  ahvays  occurs  alK)ut  the  middle  of  the  intermenstrual 
pericxl  and  extends  into  the  second  hnlf  of  it,  and  the  date  of  the 
•iatermenstrual  pain  seems  to  tlepend  on  the  date  of  the  begumuig 


INTKHMENCTRFAL  PAIN 


1.13 


of  the  following  tTu*n8lrual  perirMl  and  not  nii  tliai  ai  iUv  jiivcrditi^ 
|M*ricNL 

Exact  (lata  a.s  to  tlie  fH:Ki**i^i'lii  *^f  rrfi:iilar  fiioti^tniation  and  the 
lx*giiiuiiig  of  the  iiitornienstrual  paiji  shuithl  Ix*  unnk  in  vvory  ca^e 
for  rcTortl,  The  rharactcT  of  the  pain  varies  in  individual  ca.«ies, 
it  may  he  dull  or  it  may  be  *slmrp;  it  is  seldoin  paroxy^inaL  It  is 
situates  1  in  the  pel  vie  rei^ion,  just  ai=  in  dy^^Illeno^rhea.  The  pain 
last^  from  a  few  days,  u[>  to  tht>  entire  time  fmrn  its  beginiiing  until 
the  nejct  men^ttnmtion.     It  genc^ially  Iast.s  three  or  four  days. 

Internien.««trual  |«iin  may  )x'  pn^sent  during  all  of  a  woman*s 
>  OienstruaJ  life.  \\v  have  no  assurance  that  it  will  cease  short  of 
Ihe  menopause.  It  d^M^^  not  seem  to  be  associated  witii  dysmenor- 
rhea, although  prcHisr*  information  on  this  point  is  lacking,  hs^  it  is 
on  the  que^stion  of  its  assoriation  witli  regnlarity  and  irn'gularity 
of  men?^  niation.  There  is  a  very  great  probal jility  that  many  casc»s 
rated  a-s  im*gularity  of  [minful  menstruation  woidfl,  if  analyzed 
carefully,  be  fountl  to  Ix:  eas<\s  of  intermenstrual  pain. 

In  a  majority  of  eases  of  intermenstrual  pain  the  suffering  is 
aeconjjmnied  by  a  vaginal  discharge,  either  as  a  watery  leueojrfiea, 
or  a  yellowish  or  bloo<l-stained  discharge.  Often,  a  uterine  lesion, 
ach  as  endometritis,  a  p^»Iyp,  or  a  sul>miieous  fibroid  will  Ik*  found 

explain  the  leueorrhea.  As  a  rule,  no  definite  relation  has  been 
efitablishtMl  hetwet^n  ix*Ivic  lesions  and  intermenstrual  {)ain. 

As  regards  the  causation  of  this  affeetion,  Kelly  is  inelintMl  to 
agn*c'  with  Sir  \\'illiam  Pric^stly.  who  first  reiK)i'tetl  fom*  eases  rjf  the 
disorder  in  1S71  iBrit.  Med,  Jour.^  Vol.  II.,  ji.  6S3).  His  theory 
b  that  UJider  normal  contlitions  previous  to  menstruation,  one  or 
fjoth  ovarie**  tx*eome  (congested,  tin*  congestion  |X'rsi.^ting  tlu'ougli 
menstruation  and  for  a  few  days  after  This  congestion  is  attende*! 
by  no  signs.  Under  ahnonnal  conditions,  lx*causc  of  changes 
in  the  ovaries  not  undei-stoorl,  the  congestion  b(*gins  earli(T 
ihan  usual  and  is  attende<l  by  jx-hic  pain.  Therefore  the  j>ain 
IS  relatic^n  to  the  cortiing  perirMl  aiul  not  to  that  which  has 
prpco<ied  the  pain.  In  the  ea^es  ol>scrvT'd  clinically  such  a  relation 
U  found  to  exist. 

Physiciajis  are  urged  to  repuj*t  ease's  of  intermenstrual  jjain  with 
exactness©  so  that  tlata  may  lx>  in  hand  as  to  this  interc\sting  and 
fic^gleeted  affection.  Besi<les  the  patient's  age  and  soi'ial  condition, 
the  following  points  should  Ih>  nottxl: — (1)  Day  of  the  month  on 


134  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

which  the  last  menstruation  began.  (2)  Date  at  which  intermen- 
strual pain  began.  (3)  Date  at  which  the  following  catamenia 
began.  (4)  Length  of  time  the  pain  lasts,  and  its  character.  (5) 
Date  when  intermenstrual  pain  was  first  noted.  (6)  Full  details 
of  a  normal  menstruation,  i.e.,  exact  interval  between  beginning  of 
each  two  catamenia,  duration  of  the  flow  in  days,  amount  of  flow 
in  napkins  each  day,  occurrence  of  pain  and  leucorrhea.  (7) 
Whether  or  not  intermenstrual  pain  is  attended  by  a  vaginal  dis- 
charge, and  if  so,  its  amount  and  character.  (8)  If  a  pelvic  exam- 
ination has  been  made,  note  the  findings. 


MENORRHAGIA  AND  METRORRHAGIA 

Menorrhagia  (monthly  bleeding,  from  Aty>e?,  menses,  and 
prjyvt'jvai^  to  burst  forth)  an  excessive  loss  of  blood  at  the  men- 
strual periods,  and  metrorrhagia  (uterine  bleeding,  from  y^yj'r^, 
womb,  and  fnfy^^vai^  to  burst  forth)  a  loss  of  blood  independent 
of  menstruation,  are  two  terms  which  frequently  can  not  be  used 
with  discrimination  because  the  two  conditions  so  often  coexist. 
That  is  to  say,  a  metrorrhagia  becomes  a  menorrhagia  when  the 
menstrual  period  arrives,  and  menorrhagia,  as  in  the  case  of  a 
submucous  fibroid,  in  the  course  of  time  becomes  a  metrorrhagia. 
Therefore  it  will  Ik^  convenient  to  considcT  the  two  symptoms 
together,  Ix^aring  in  mind  the  fact  that  mc^riorrhagia  may  be  due 
to  constitutional  dis(»ase,  whereas  metrorrhagia  is  always  due  to 
disease  of  th(^  pelvic  organs.  Menorrhayia  is  a  relative  term,  for 
what  is  a  moderate  flow  for  one  woman  would  be  rated  as  excessive 
by  another.  Therefore,  before  pronouncing  that  menorrhagia 
exists  in  any  given  cas(»,  th(^  physician  must  inquire  minutely  as  to 
the  patient's  normal  habit  of  menstruation,  getting  the  number  of 
days  that  the  flow  lasts,  and  the  number  and  size  of  the  napkins 
used,  and  whether  they  are  well  saturated  or  not.  As  a*  rule, 
under  normal  conditions,  most  of  the  flow  occurs  during  the  first 
two  or  three  days.  Find  out  whether  this  is  the  case.  Supposing 
that  it  is,  a  loss  of  blood  of  a  like  amount,  lasting  through  five  or 
six  days,  would  constitute  m(*norrhagia.  If  the  flow  is  increased 
during  the  normal  mc^nstrual  time  it  is  one  type  of  menorrhagia, 
and  a  menstruation  unduly  prolonged  in  point  of  time  is  another. 


MENORIlHAfJU  AND   METRORRILVOIA 


13S 


Only  painstaking  quest ioniiig,  or  the  results  of  olxservalion  by  a 
nurse^  mil  establisli  the  facts. 

In  investigating  a  case  of  nieiion-hagia  live  constitutional  causes 
ehould  be  considered  fir^^t,  then  thi*  local  causes.     Only  the  habit 

Pof  excessive  menstruation — not  forf>npor  two  piTimls  only  ^should 
necessitate  a  diagnosis,  and,  particularly  in  the  case  of  unmarried 

|girls  and  women,  constitutional  dis(>a*ses  must  bi*  eliminated  care- 
fully before  procc»e<ling  to  local  examination.  The  establishment  of 
menstruation  at  puberty  is  frequently  attended  by  menorrhagia 
for  several  perioils.     Faniily  tendencies  are  to  be  l^ome  iu  mind. 

_ln  some  families  it  is  the  habit  for  the  women  to  flow  freely,  and  in 
athers  the  reverse*  liokLs  true. 

I.    CoNSTITirriONAL  CaITSES    OF  MeNORRUAGIA 

The  following  l>li>o<l  conditions  are  known  to  be  attended  by 
nienorrhagia: — hemophilia,  (jurpura,  scnirvy,  leukemia,  the  uremia 
of  nephritis,  and  sc^vere  rholemia  or  jamidice.     The  various  in- 
-feetious  diseases,  Ntich  as  small-j>ox,  scarlet  fever,  cholera,  tyfihoid 
rfever,  influenza,  and  malajial  fevvr,  often  have  excessive  menstrua- 
tion as  a  symptom.     Menorrhagia  is  not  imcommon  in  the  early 
tagef^  of  pulmonary  phthisis,  although  amenorrhea  is  the  rule  in 
.  disi*ast>.     It  also  occurs  iti  syphilis  and  in  the  chronic  poison- 
of  alcohol,  lead,  or  phosijliorus,  anil   in  organic  heart  tliscase 
and  in  eirrhoeis  of  the  liver.    An  excessive  menstrual  flow  is  apt 
to  attend  the  initial  stages  of  any  acute  constitutional  disease. 
lleart  disi*ase  favors  cliniacteric  hemorrhage, — a  feeble  or  an  in- 
jfficient    iieart    making  for    pelvic  congestion   with  consequent 
nienorrhagia  or  nietrorrhagia. 

IL   TiOCAL  Causes  of  Mknohrhagta  and  Metrorrhagia 


Having  rule<l  out  the  constitutional  causes  of  menorrhagia,  the 
phyHieian  should  make  a  careful  vaginal  examination  in  all  cases  of 
persistent  uterine  hemorrhage,  whether  oct^inTing  at  the  menstrual 
periods  or  not. 

TTie  local  causes  may  be  enunieratetl  as  follows: — 

Uterine  ccmg^ion. 


136  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

Endometritis. 

Polypi. 

Abortion. 

Extra-uterine  pregnancy. 

Subinvolution  of  the  uterus. 

Submucous  fibroids. 

Cancer  of  the  cervix. 

Cancer  of  the  fundus. 

Sarcoma. 

Chorio-epithelioma. 

Inversion  of  the  uterus. 

Backward  displacements  of  the  ut<?rus. 

Inflammation  of  the  tubes  and  ovaries. 

Small  cystic  degeneration  of  the  ovarie^s. 

Ovarian  cyst  with  twisted  pedicle. 

Arterio-sclerosis  of  the  uterine  blood-vessels. 

Vaginitis  and  injuries  of  the  vulva  and  vagina. 

It  may  Ixj  well  here  to  point  out  the  probable  diagnosis  to  Ix* 
obtained  from  the  patient's  age,  whether  or  not  she  is  a  virgin,  or 
whether  or  not  she  has  ever  been  pregnant. 

The  following  affections  are  common  to  the  virgin,  the  married 
woman,  and  the  multipara: — ovarian  tumors,  fibroids,  and  cancer 
and  sarcoma. 

Arterio-sclerosis  of  the  small  blood-vessels  of  the  uterus  has  been 
described  by  Henri  Amal,  Palmer  Findley,  and  others.  It  is 
essentially  a  disease  of  the  senile  uterus,  although  cases  have  been 
reported  in  the  uteri  of  women  between  thirty  and  forty  years  of 
age.  As  yet  we  do  not  know  how  often  this  condition,  which  seems 
to  be  not  very  uncommon,  is  the  cause  of  hemorrhage. 

1.  The  patient  is  a  virgin,  and  (a)  is  under  the  age  of  trventy-five. 
Increase^  in  the  amount  of  menstrual  flow  is  most  often  due  tout^^rine 
congestion,  perhaps  brought  on  by  exposure,  or  over-exertion  dur- 
ing a  m(»nstrual  period,  or  it  may  be  due  to  a  glandular  polyp.  In 
the  latter  cavse,  the  polyp  generally  produces  metrorrhagia  as  well 
as  menorrhagia,  and  thus  we  may  distinguish  between  hemorrhage 
due  to  congestion  and  that  due  to  a  polyp.  Uterine  congestion  is 
the  direcrt  cause  of  all  uterine  hemorrhage,  the  more  remote  causes, 
such  as  displacements  and  inflammation  of  the  tubes  and  ovaries. 


MENORRHAGIA   AXD  METRORRHAniA 


137 


\mng  many,  Chronk-  rndoiiit'tritis,  foniuTly  thoyjfj;ht  to  Ik*  ilu- 
coimiion  cause  of  utfTinr  I4<*c*lin^»  if«  now  n^gardinl  as  nhitivcly 
5,  with  the  exception  of  the  i>oly|>oicl  and  the  hyperplastic  varie- 
ties. 

(b)  Menorrhagia  may  be  due  to  backwaRl  displacement  of  the 
uterus  at  any  age  Ix^fon^  the  nienoi>au80.  Fi^oni  twenty-fi\'e  to 
thirty-five  ntrrine  fil>roi<is  of  r^ylmiurous  evohition  are  an  inijiortant 
euuse  of  both  menorrliagia  and  mt^trorrhagia.  Cancer^  4^^peeially 
cancer  of  the  fiuidus^  is  to  l>e  thought  of  a«  a  cause  of  metr(»rrhagia 
after  the  agt*  of  thirty-five,  A  w^ater\^  vaginal  discharge  accom- 
panies the  flow  vrry  often  in  the  case  of  cancer  of  the  fuuihis;  some- 
times abo  in  fibroids. 

The  facta  may  l>e  sunmiarized  in  the  following  table: — 


MENORRHAGIA   AND    Min^RORRIIAGIA    IN    VIRGINS, 


Age,  MENouiiHAOLi, 

r  ITterinc  congestion. 
ITnder  twenty-five.  <  Backward  displacements. 


I 


Cofistitutional  liiaeases. 


MBTRORRHAOtA. 


Utcnnt*  i>olyp. 
I  Rarely,  submucous  fibroid. 


L 


enty-fivo  to 
forty. 


Uterine  congestion, 
Endnfn«'trilia, 
Burkwurd  <  liHplafH'itiL'ntjs. 
SubniucoiLs  fibri»id* 


''  Utt»rinp  polyp. 
Submucous  fibroid. 
Rarely,  cancer  or  sarcomu  of 
the  botly  of  the  utenis*. 


Over  forty.      h 


Submucous  fibroiti 
Eridornetrilis, 
Uterine  conieestion. 
^Backwuni  di^pbctnncnts. 


Submucous  fibroid. 

l^terinc  polyp, 

CnmxT    or    sarcoum    of    tho 

bwly  of  the  uterus. 
Rarely,  cancer  of  the  cervix. 


2.  The  patient  is  not  a  vixgin,  and  (a)  has  never  beefi  preijmtnL 
WTien  a  jiatient  has  Ix'^^n  niarri«Hl  a  short  time  antl  )s^ves  a  histon' 
of  gonoeoccus  infertion  with  |mriilent  vaj^inal  ilischar^^e  ami  smart- 
illgon  urination,  the  probability  is  that  if  she  lias  nieiiorrha^ia  she 
in  suffcTing  with  gonorrheal  endometritis  and  i>erha|)s  with  jiyosal- 
frinx  hho.  If  gonoeoeeufi  infertion  is  not  present  menorrliagia  in 
such  a  patient  pn)l)ably  means  uterine  eongefciitiun  clue  to  excessive 


138  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

sexual  intercourse.  It  may  mean,  however,  a  tear  of  the  hymen 
from  violent  coitus,  or  a  bleeding  urethral  caruncle. 

If  there  are  any  symptoms  of  pregnancy,  such  as  a  preexisting 
amenorrhea  with  sharp  pain  in  one  groin  and  tenesmus,  irregular 
metrorrhagia  might  indicate  extra-uterine  pregnancy.  In  this 
case  look  for  decidual  membrane  in  the  blood  passed  (see  Chapter 
XIX.,  page  344),  or  it  might  mean  an  early  abortion.  The  differen- 
tial diagnosis  of  these  two  conditions  will  be  found  in  Chapter  XXII., 
page  441. 

In  the  absence  of  the  signs  and  symptoms  referred  to,  metror- 
rhagia points  to  a  uterine  polyp. 

Menorrhagia  becoming  gradually  metrorrhagia  in  a  woman  over 
thirty-five  years  of  age  suggests  a  submucous  fibroid,  and  metror- 
rhagia occurring  after  forty,  always  should  arouse  suspicion  of 
malignant  disease;  sterile  married  women  and  virgins  being  more 
prone  to  cancer  of  the  body  of  the  uterus  than  to  cancer  of  the 
cervix,  and  parous  married  women  to  the  latter. 

(6)  The  patient  has  been  pregnant.  If  a  pregnancy  is  not  very 
distant  in  the  past,  metrorrhagia  is  probably  due  to  subinvolution; 
if  metrorrhagia  also  is  pn^sent,  there  may  be  retained  products  of 
conception,  or  inversion.  Metrorrhagia  coming  on  six  weeks  or 
so  after  labor  may  mean  chorio-epitholioma.  If  pregnancy  was  in 
the  distant  past,  endometritis  in  various  forms,  utcjrine  displace- 
ments, fibroids,  or  cancer  of  the  cervix  must  Ix)  thought  of.  Metror- 
rhagia beginning  after  the  menopause  has  become  well  established 
almost  invariably  means  cancer. 

(c)  The  patient  is  pregnant.  Uterine  hemorrhage  beginning 
after  one,  two,  or  three  months  of  amenorrhea,  with  the  occurrence 
of  some  of  the  symptoms  of  pregnancy,  points  toward  threatened 
abortion,  and  if  regular  rhythmic  pains,  like  labor  pains,  are  present 
also,  to  inevitable  abortion.     (See  Chapter  XXII.,  page  439.) 

Irregular  hemorrhage,  perhaps  with  the  passage  of  decidual 
membrane,  accompanied  by  pain  in  one?  groin  and  bearing  down, 
with  any  symptoms  of  pregnancy  may  mean  extra-uterine  preg- 
nancy.    (See  Chapter  XIX.,  page  351.) 

In  the  later  months  of  pregnancy  hemorrhage  may  be  due  to 
placenta  previa  or,  rarely,  to  carcinoma  of  the  cervix. 

The  following  table  summarizes  the  facts  as  regards  uterine 
hemorrhage  in  married  women: — 


PRIMARY  AMENORRHEA 


139 


MENORRHAGIA   AND   METR0RRH.\G1A   IN   M.\RRIED   WOMEN. 


hfuUiparip, 


Freynaney. 


PNgnane^, 


MSSORRBAQIA, 


"Uterino  rongostirm. 
Inflmiimntion    of    tubes 

Hiid  ovaritis. 
Submucous  fibroid. 


f  Sub-in  vol  uti  on » 
<  EntliiTnetritLs. 
I  Hubniyfoiiji  fibroid. 


(  Rarely,  menstruation 
(      during  pregnancy. 


Metrorrhagia. 

Uterim'  polyp. 
Sub-muoous  fibroid. 
Ext ra-uterint'  [>regnaney 
RuiJtuft^d  h>^ien* 
Cancer    or    sarcoma    of    the 
body  of  the  u  ten  is. 
^Rarely,  cancer  of  tlie  eervnx. 

^  Retained  products  of  concep- 
tion. 

Cancer  of  the  rervix. 

Inversion. 

Senile  endometritis. 

Chorio-<"pilhelioina. 

Rarely,  cancer  of  the  body  of 
the  uterus. 

^Threatened  abortion. 

Inevitable  abortion. 

Placenta  pnevia. 

Extni'Ulerine  pregnancy. 
^  Rarely,  cancer  of  the  cervix. 


AMENORR^A 


Imemorrhea,  or  absence  of  the  nHmstnial  flow  (from  «,  privative, 
MVs  month,  and  /J/£f>,  to  flow),  may  be*  elaNsifinl  as  follows: — (1) 
Priraan'  amenorrhea,  or  emansio  mcnsiuin,  in  which  menstruation 
has  failed  to  appear  at  the  usual  age;  and  (2)  secondary  amen- 
orrhea, or  suppressio  mensium,  in  w'hieh  mensiruation  has  ceA^fnl 
after  it  han  hotm  estalilished. 

I.  Primary  Amenorrhea.^ Primary   amenorrhea   is  due  to   (a) 

lure  of  grouih  of  the  uterine  organs^,  perhaps  coincident  witii 

rk  of  general  l)oiliIy  growth,  |XTha|>s  not,  or  to  (h)  atresia  of  the 

hymen  or  of  the  vagina.    The  last  condition,  called  cryplomenorrhea, 

is»»  gftrictly  speaking,  not  amenon*hea  at  all,  but  a  retention  of  nien- 

trual  fluid.    As  we  are  considering  the  symt>toni  of  alisence  of 

^memftruation,  it  is  convenient  to  include  cryptomenorrhea  in  this 

place. 

(a)  Failure  of  Growth, — A  girl  ha\4ng  a  stimtefi  physicjue  may 
hskve  tardy  growth  of  the  uterine  organs  also,  and  menstruation 


140  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

may  appear  later  than  normal.  This,  however,  is  not  so  often  the 
ease  as  it  is  to  find  a  gocxl  physicjiu^  and  abnormal  uterus  and 
ovaries.  The  uterus  which  exhibits  faults  of  development,  such 
as  utenis  dideli)hys,  uterus  bicomis,  and  uterus  bipartitus  (see 
Chapter  XIII.,  page  199),  does  not  ordinarily  have  amenorrhea  as 
a  symptom,  although  rudimentary  uterus,  when  associated  with 
atresia  of  the  vagina,  generally  does.  Arrests  of  growth,  on  the 
other  hand, — infantile  uterus  and  congenital  atrophy  of  the  uterus, 
— are  commonly  attend(»d  by  amenorrhc^a.  Infantile  utenis  is  a 
relatively  common  condition.  The  uterus  is  narrow  in  proportion 
to  its  length,  has  a  long  cervix  and  a  short  body,  and  is  situated 
w-ell  back  and  high  in  tlie  pelvis  at  the  end  of  a  long  vagina.  The 
cervix  is  conical  and  anteflexcMl,  and  the  os  a  "pin-hole  os.''  The 
patient's  figure,  breasts,  hair,  and  voice  are  g(*nerally  of  the  fem- 
inine type.  Congenital  atrophy  of  the  uterus  is  a  rare  condition. 
Here  all  the  dimensions  of  the  utcTus  are  reduced  while  the  normal 
proportions  are  retained.  The  condition  has  been  found  in  dwarfs 
and  cretins,  and  in  early  tuberculosis  and  chlorosis.  It  is  supposeil 
that  in  these  cases  the  uterus  attained  a  proper  growth  to  the 
virgin  tyj)e,  and  that  atrophy  followed. 

Both  of  these  conditions  are  gen(Tally  associated  with  anomalies 
of  the  ovaries.  (Sec  Chapter  XML,  p.  285.)  Congenital  absence 
of  both  ovaries  is  extrenu^ly  rare.  It  is  of  course  accompanicn^l  by 
absolute  am(»norrhea.  Abscaice  of  one  ovary  does  not  affect  men- 
struation. Faulty  growth  of  the  ovari(\s  accompanies  both  infantile 
uterus  and  rudimentary  uterus.  The  ovaries  are  small  and  amen- 
orrh(^a  may  exist. 

(6)  Atresia  of  the  Hymenj  or  of  the  Vagina, — Cryptomenorrhea 
may  be  caused  by  imperforate  hymen  (see  Chapter  XXL,  page  396),  or 
by  th(*  diffen^nt  varieties  of  atresia  of  the  vagina  (see  Chapter  XX., 
pag(\s  357,  359).  In  these  cases  th(^  ovaries  are  functionally  active. 
Menstrual  molimina  an^  pres(^nt  and  may  be  attended  by  severe 
cramj)  pains,  and  then^  may  b(^  vicarious  menstruation  from  the 
nose  or  other  mucous-membran(*-lined  cavities.  The  menstrual 
fluid  collects  behind  the  obstruction,  which  may  be  situated  any- 
wh(T(^  from  the  hynu^n  to  the  internal  os,  though  it  is  usually  in  the 
vagina,  and  by  distending  first  the  vagina,  then  the  uterus,  and 
finally  the  tubes,  causes  the  conditions  known  as  hematocolpos, 
hematometra,  and  hematosalpinx,  respectively. 


SECONDARY  AMENORRHEA 


141 


Tlie  pfttipnt,  who  has  pa.S8<xl  the  usual  turio  fur  pyl^erty,  pro- 
sen  is  a  normal  figure  and  ha.s  normal  feniiniuo  l^reajsts,  hair,  and 
voico.  She  roinplains  ot  aliscnt'e  of  itieustriiation  and  suffers  with 
menstrua)  niolimina — generally  j^-vere  cramps  in  the  lower  ab* 
(lomen. 

2.  Secondary  Amenorrhea*— Tin •  following  cauKC^  be.sides  the 
menofiausi'  may  \n'  eruiUKTatrd  as  afroimtirig  for  the  et^ssation  of 
menstniation  after  it  haj^  k-en  eytablishcHl; — (a)  preguaney  and 
lactation,  (6)  atrophy  of  the  ovaries,  (c)  constitutional  diseases, 
((/)  exhaustion  anrl  shoek»  and  (e)  retention  of  menses  from 
acquired  atresia  of  the  genital  eanah  Cessation  of  menstruation 
nmy  h)e  temporary  or  pi'rmnnent;  if  the  latter,  it  eonstitutes  the 
menopause. 

(a)  f^refjtmficy  nmi  LavintiufL — Pn-gnanry  nmst  b<*  eonsidi^red 
the  chief  cause  of  amenorrhea  and  the  physieian  will  du  well  to 
bear  this  constantly  m  niiml,  even  in  the  cases  where  tiie  prnlmhility 
of  it6  btnng  present  seems  to  bi»  snialh  It  is  to  bo  rememlx^ed  that 
menstruation  may  f>eeasionaIly  oerur  iluring  pregnancy  (see  Cha|> 
tcr  XXIL,  page  419).  The  menses  are  usually  absent  dming 
lactation »  thougli  not  always.  Prolonged  lactation  may  indtiec 
lactation  atrophy  of  the  ovaries  with  cons(H|ucnt  amennrrhca. 

{h)  Atrophy  of  the  Oi an e.v.— Not  much  is  known  alx»ut  the  eon- 
tlitions  which  cause  atro[)liy  of  the  ovaries.  When  atrophy  has 
taken  place  the  oophoron  of  the  ovary,  the  egg-lx'aring  zone,  u? 
smaller  and  harder  than  normal,  and  becomes  transformed  into  a 
layer  of  dense*  fibrous  tissue. 

Ovarian  atrophy  lias  been  reported  in  women  who  have  nursed 
their  childn*n  a  veiy  long  time,  aiifl  also  in  tlie  following  diseases: — 
the  exanthemata,  myxiiiema,  marked  anemia,  arnl  diabetes. 
We  are  justifR^l  in  suiJi»o.sing  that  ecKsation  of  function  of  the 
m'aiim  iJ*  the  direct  cause  of  amenorrhea  ui  the 

(r)  Con^iilulionnl  O/.v^^ri.'^e^f,— Wheth<*r  denif)nstrable  degenera- 
tive tij^ue  changes  occur  onlinarily  when  amenorrhea  is  prestiit  we 
«lo  not  know.  There  is  no  doubt  tFiat  the  ovaries  show  a  decrease 
iti  siate  imder  such  conditions. 

Sud<lenly  acciuirni  ol>c»sity  is  (jften  attend^tl  by  amenorrhea,  so 
also  are  the  early  stitges  of  pulmonary  |»hthisis.  In  the  hornier 
caf*c*  it  is  ap|>arently  du<'  to  anemia  and  over-nutrition,  an*l  in  the 
tatter  to  anemia  and  malnutrition*     Other  instances  of  tlie  latter 


142  THE  CHIEF. SYMPTOMS  OF  PELVIC  DISEASE 

cause  arc:  tuberculosis  of  the  kidney,  diabetes,  chronic  nephritis, 
malaria,  chronic  mercury,  lead,  or  alcohol  poisoning,  leukemia,  and 
the  morphine  habit. 

If  amenorrhea  is  not  directly  dependent  on  the  blood  state  it  is 
related  to  the  condition  of  the  nervous  system. 

(d)  Mental  overwork  in  schoolgirls  is  sometimes  responsible  for 
the  absence  of  the  menstrual  flow.  Sudden  grief,  worry,  or  fear, 
or  grave  hysteria,  melancholia,  or  some  of  the  other  psychoses,  are 
often  attended  by  amenorrhea. 

{e)  Amenorrhea  from  retained  menstruation  due  to  atresia  of  tlie 
genital  canal  is  comparatively  rare.  Necrosis  of  the  vagina  or 
cei-vix  following  prolonged  and  difficult  labors,  the  wearing  of 
neglected  pessaries,  or  injury  of  the  vagina  from  caustics,  occasion- 
ally cause  cicatricial  stenosis  to  the  extent  that  the  secretions  of 
the  uterus  are  dammed  up.  In  this  event  the  absence  of  menstrua- 
tion will  be  attended  by  crampy  pains  and  menstrual  molimina. 

If  a  girl  does  not  menstruate  after  she  has  passed  her  sixteenth 
year,  the  physician  should  inquire  into  the  state  of  her  general 
health,  making  whatever  physical  examination  is  necessary  to 
arrive  at  a  diagnosis  of  systemic  disorder.  The  blood  should  be 
examined  both  as  regards  the  number  of  red  corpuscles  and  the 
percentage  of  hemoglobin.  Failing  to  find  any  constitutional  cause 
for  the  amenorrhea,  a  local  examination  should  be  made,  and  except 
in  the  rare  cases  of  phlegmatic  girls  of  good  sense,  with  the  aid  of 
an  anesthetic. 

Should  the  patient  oxperienc^e  menstrual  molimina  without  a 
flow,  local  examination  should  l)e  made  without  a  previous  inquiry 
into  the  constitutional  state. 

Neglect  to  investigate  has  resulteMl  in  serious  harm  in  the  cases  of 
retained  menstruation  from  im{)(Tforate  hymen  or  atresia,  through 
dilatation  of  the  uterus  and  tubers  with  rupture  of  the  latter  into 
the  abdominal  cavity. 

In  women  who  hav(*  been  exposed  to  sexual  intercourse,  preg- 
nancy should  always  hi'  in  th(^  physician's  mind  as  a  probable  cause 
of  amenorrliea,  and  aft(T  the  foi-tieth  ye^ar  the  possibility  of  the 
bc^gimiing  of  the  menopause*  should  be  considered. 

In  every  casi^  of  amenorrhea  the  general  physical  condition  of 
the  patient  should  first  engage  the  physician's  attention, — ^the 
nervous  system  and  the  blood  state  being  thoroughly  investigated. 


LEtCORRHE.\ 


143 


LEUCORRHEA 

Lc*ucorrhea,  or  *' whiter"  (from  ^coxfJy,  white,  and  fima^  flow), 
IS  the  gefirrio  name  commonly  given  to  any  discharge  from  the 
vulva,  other  than  blcKnl. 

rriiler  normal  renditions  the  inner  surface  of  the  \iilva  is  simply 

Tnoif?t  during  the  intermenstrual  time,  exeept  just  before  and  jut^t 

after  menstniation,  when  the  clisehartije  may  be  enough  to  neceHsitate 

wearing  a  napkin*     The  normal  moif^ture  is  made  up  of  elements 

from  four  different  sourees,  in  varying  amounts,  namely:  secretion 

frora  the  uterine  eavity  jiroper,  secretion  from  the  rer\neal  canal, 

epithelium  from  the  vat^ina.  and  secretions  from  the  vulva.     The 

eecretiun  from  the  uterine  eavity  is  a  clear^  trarLspari*nt  fluid,  small 

inamount,  and  ha\ing  an  alkaline  reaction;  that  from  the  cervical 

I  canal  is  tenacious,  transpaniit,  and  thick  like  the  white  of  an  egg. 

[The  epithelium  cast  off  from  the  vagina  is  mixed  with  the  uterine 

ret*cretions  to  form  a  milky  fluid  which  is  generally  small  in  amount. 

The  sweat  and  ^eliaceous  glands  of  the  lodva  make  a  secretion 

of  considerable  amount.  fi»rming  smegma,  which  is  found  in  the 

folds  about  the  nymph;e  ami  under  tlie  prepuce.      Besiiles  this 

there  is  the  glairy  mucus  secreted  by  the  glands  of  Bartholin  and 

Skene. 

Char.\cter  of  thk  Discil%hoe  in  Lkucorrhea 


We  will  now  consider  the  discharges  undt^r  almonna!  conditions, 
taking  up  first  the  different  cliaracters  of  tin*  discharges  and  thru 
the  probable  meaning  of  the  various  dischargers  occiuring  in  girls 
and  women  of  different  sfx-ial  conditirms. 

White  Discharge.— It  is  wliite,  creamy  or  curdy,  or  visciil  and 
dflftr.  It  stiffens  the  linen  but  does  not  st^in  it.  It  may  mean 
,  jHvic  congestion,  endometritis,  or  laceration  of  the  cervix,  with  or 
without  uterine  nmlpasition. 

Yellow  Discharge. — It  is  light  j^ellow  (nuico-punilent),  marketUy 
yellow  (purulent) I  or  greenish  yellow  (gonococcus  infection).  It 
may  mean  purulent  endometritis,  a  j>elvic  absi-ess  discharging 
tfu'ough  the  vagina,  py*mietra  ass<M'iated  with  cancer  of  the  cervix, 
mudf  most  frequent  of  all,  gonococcus  infection  of  vaginai  cervix, 
thra,  or  the  vulval  glands. 


144  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

Watery  Discharge. — ^This  is  a  clear,  colorless  fluid  that  does  not 
stiffen  the  linen.  It  may  have  color  enough  to  stain  the  Uncn. 
It  may  mean  uterine  congestion,  endometritis,  intermittent  hydro- 
salpinx, submucous  fibroids,  or  cancer  of  the  uterus,  especially 
cancer  of  the  body.  Under  watery  discharge  must  be  included 
leakage  of  urine  from  a  urinary  fistula  or  incontinence.  Here  the 
odor  of  urine  is  apparent. 

Fetid  Discharge. — Foul-smelling  discharge  may  be  purulent  or 
watery  in  character  arid  results  from  necrosis  of  tissues.  It  may 
be  caused  by  a  neglected,  retained  pessary,  by  a  sloughing  sub- 
mucous fibroid  or  polyp,  by  decomposed  products  of  conception, 
and,  most  frecjuent  of  all,  by  cancer  of  the  uterus,  especially  cancer 
of  the  cervix;  the  discharge  in  the  last  case  having  a  characteristic 
odor. 

Bloody  Discharge. — ^A  discharge  tinged  with  blood,  occurring  dur- 
ing the  intermenstrual  period,  stains  and  stiffens  the  linen.  It 
may  be  due  to  endometritis,  laceration  of  the  cervix,  submucous 
fibroid,  polyp,  vaginitis,  or  cancer.  A  scanty  hrownuh  discJianje 
lasting  for  several  weeks  may  indicate  a  disintegrating  uterine  decidna 
in  the  case  of  ruptured  tubal  pregnancy  (see  Chapter  XIX.,  page  353), 
or  it  may  mean  the  slow  breaking  up  of  a  blood  clot  within  the 
uterine  cavity. 

OCCURREXCE  OF  LeUCORRHEA 

Leucorrhea  in  Children^ — ^The  immediate  cause  of  leucorrhea  in 
children  is  vulvitis.  A  white  discharge  occurs  sometimes  in  poorly 
nourished  children,  and  int(\stinal  worms,  dirt,  and  struma  have 
Ixvn  assigned  as  causes.  Just  how  th(?se  are  factors,  and  why  some 
chihh'en  affected  by  them  have  leucorrhea  and  others  do  not,  has 
not  b(^en  explaint^l.  One  author  has  assigned  the  staphylococcus 
as  a  cause  and  others  hav(»  found  a  large  variety  of  bacteria  in  these 
cas(\s.  Masturbation  is  undoubtcHlly  a  cause  of  vulvitis  and  there- 
fore of  leucorrhea  with  a  white  discharge^  never  of  leucorrhea  with 
a  purulent  discharge.  The  practic(^  is  by  no  means  infrequent 
among  neurotic  children.  (S(m^  Chapter  XXVIIL,  page  574.)  Pu- 
rulent vulvitis  is  (lu(^  to  gonococcus  infection  in  a  majority  of  cases. 
R(Tent  bacteriological  investigations  of  (epidemics  of  this  disease 
in  institutions,  public  baths,  and  elsewhere  prove  that  thegonococcus 


LEUrOHRIlKA 


U5 


IB  present  in  nearly  all  nf  ihr  i-u-si's  and  tliat  the  clLse^ist^  is  most 
[frcMjuent  in  clulrlren  imiler  five  years  of  age.  There  occurs  rarely  in 
^little  girls  a  vulvovaginitis  with  purulent  tlise}iarg<%  perhaps  tluo 
jto  the  staphyloeoecas.  Vaginitis  is  generally  asvsociated  with 
v\il\itis,  and  ga!pingiti*s  ilevelops  in  a  eertain  proportion  of  the 
leases.  The  disea.^  leavers  disabling  traces  not  only  in  closure  of 
the  tubes  but  also  tn  the  form  of  adhesions  of  the  nyniphte  to  the 
'prepuce  and  to  each  other.     (See  Chapter  XXL,  page  394,) 

Leucorrhea  in  Virgins.— Transitory  leucorrhea  in  a  virgin  may  be 

.  due  to  a  [X'lvic  congestion.     The  discliarge  under  these  conditions  is 

I  generally  either  white  ami  curdy,  or  clear  antl  viseiil.  or  a  mixture 

of  the  two.     Sometimes  the  leucorrhea  if  of  the  vistdd  tyjx?  is  from 

the  .secretion  of  the  glands  of  Bartholin  causeil  by  sexual  ft^elings. 

In  only  exceptional  instances  can  a  male  physician  ascertain  the 

faetii  bi  this  respect,  so  tliat  if  such  a  state  of  affftirs  is  susjicctefl 

the  patient  should  be  referred  to  a  woman  j>hysician.     Persistent 

leucorrhea  in  a  vii-gin  is  due  to  pelvic  congestion  or  c*ndometritis 

in  the  young,  or,  in  the  old,  may  be  due  to  cancer  of  the  body  of 

the  uterus  or  to  a  submucous  filiroiil.     llenorrhagia  is  generally 

an  attending  symptom.     A   local  examination   should   be  made 

,  because  in  this  way  oidy  can  an  intelligent  opinion  be  formed  of 

'  the  condition  of  tht*  uterine  organs.     After  the  examination  has 

been  made  the  state  of  the  general  health  should  nnieive  ciireful 

^attention  in  the  way  of  corivctiiig  anemia,  whether  or  not  local 

treat  nient  is  employed  in  con  junction  wnth  it. 

Leucorrhea  in  Married  Women, — In  women  who  are  accustomal 
to  sexual  intereoujif*e  a  white  discharge  may  mean  simple  pelvic 
.congestion.     Tliis  is  not  an  imusual  condition  in  the  recently  mar- 
ried, the  congestion  of  tlve  pehdc  organs  Ixing  excessive  bc^eause 
of  intemperance  in  coitus.    So  also,  a  leucorrhea  may  result  from 
habitual  incomplete  coitus,  part  of  the  discharge  coming  from  the 
Uterine  cavity antl  part  ivom  Bartholin's  glands.     '*  Whites**  aiv  a 
fffj'mptom  of  laceration  of  the  cervix,  (Tosions,  endouietritis,  and 
uterine  misplacements.    A  yellow  discharge  is  found  hi  tin*  \tm- 
fOus  sorts  of  vaginitis  (st^e  Chapter   XX.,  page  361),     Wiginitis 
following  infection  rluring  or  after  confinement  is  very  common, 
anfl  also  gonorrheal  vaginitis.     The  gonorrheal  sort  is  apt  to  date 
from  marriage  or  intercourse  and  to  bi*  aecompanied  by  frequent 
and  smarting  micturition,    A  vulvo-vaginal  abscess  or  a  bubo  may 
m 


146  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

have  complicated  the  disease.  Parous  women  are  more  apt  to 
have  cancer  of  the  cemx  than  nuUipane.  This  disease  is  attended 
by  a  yellow  or  blooily  vaginal  discharge.  Retained  products  of 
conception  cause  a  bloody  discharge,  as  a  rule,  and  sloughmg 
fibroids  or  polj-pi  a  foul,  purulent  discharge,  while  a  submucous 
fibroid  causes  a  thin,  water}'  leucorrhea.  A  persisting  brownish 
discharge  may  mean  extra-uterine  pregnancy. 

Leucorrhea  in  Old  Women. — ^AVomen  who  have  passed  the  meno- 
pause should  have  no  vaginal  discharge  if  their  uterine  organs  have 
atrophied  in  a  normal  manner.  If  there  is  a  white  discharge  it 
may  be  due  to  senile  endometritis,  caused  by  old-standmg  uterine 
lesions.  A  yellow  or  bloody  discharge  means  either  senile  vaginitis 
or  cancer,  and  so  often  the  latter  that  no  time  should  be  lost  in 
investigating  the  condition  of  the  uterine  organs  as  soon  as  the 
symptom  is  reported. 

DYSPAREUNIA 

Dj'spareunia,  from  the  Greek  o'j^r:df,-u>o^^  ill-mated,  is  the 
name  given  to  pain  or  difficulty  in  sexual  intercours<\ 

Difficulty  in  accomplishing  the  sexual  act  may  be  due  to  (1) 
psychoneurological,  or  to  (2)  anatomical  causes.  Of  (1)  the 
psychoneurological  causes,  we  may  enimierate  repulsion  or  aversion 
on  the  i)art  of  the  wife.  Cases  are  on  reconi  where  women  have 
refused  to  let  their  husl^ands  touch  thorn  throughout  a  long  series 
of  years  of  married  life  b(vause  of  n^pulsion,  or  the  husbapd^s 
awkwanl  manner  of  approach,  .\nother  of  the  psychoneurological 
causes  is  vaginisnnis  (see  Cliapter  XX.,  page  378),  a  spasmodic 
reflex  contraction  of  the  levator  ani  and  other  muscles  about  the 
\'ulva  excit(Hl  by  the  slightest  touch.  This  afifection  may  be 
associated  with  actual  smallness  of  the  vagina  or  an  irritable  h)Tnen, 
or  it  may  Ixi  due  entirely  to  an  irritable  condition  of  the  nervous 
system. 

(2)  Anatomical  causes  of  both  difficult  and  painful  intercourse 
are  (a)  thos(^  situated  in  the  vulva  or  lower  vagina — a  rigid  hymen, 
a  small  vagina,  either  from  faulty  gro^vih  or  from  cicatricial  stenosis, 
clironie  vaginitis,  urethral  caruncle,  vulvitis,  a  ^^Ivo-vaginal 
al^scess,  chancres  or  chancroids  of  the  vulva,  and  kraurosis  vulva*; 
and  (6)  deeper-seated  comlitions,  of  which  the  chief  are, — ^metritis. 


STERILITV 


147 


lacerations  of  the  cervix  with  tender  cicatrieoi?,   prolapsed  and 

■  tender  ovaries,  and  masses  of  pelvic  inflanmiaton*  exudate.  It  is 
unnecessary  to  consider  ht-re  the  acute  inflammations  of  \nilva, 
vagina,  ute^u^^,  ovaries  and  tulx^s,  or  pehic  peritont*um  because, 
of  necessity,  intercoui'se  (*ott]d  not  take  place  in  the  presence  of 
BUch  conditions. 

Disproijnrtion  Iji-twc^'n  thf*  size  of  the  penis  and  the  caliber  of 
the  vagina,  or  a  tlcticit*ncy  In  the  luljricating  fluids  secrcteil  by  the 
proetate  in  the  male  and  Bartholin's  glanrls  in  the  female,  may  be 
causes  of  d>^pareunia. 

In  getting  a  history  of  imin  during;  intercourse  the  physician  must 
inquire  whether  the  pain  is  at  the  lx*ginniiig,  or  after  the  penis  has 

■  entered  the  vagina.  If  at  the  beginning,  the  cause  is  probably  to 
be  souglit  in  vnginisimis  or  in  class  (a)  of  the  anatomical  causes;  if 
after  the  penetration  uf  tlie  male  organ  the  cause  is  in  class  (i). 
Inquiry  should  be  matle  whether  the  pain  has  Ix^en  present  with 
coitus  since  the  Ix^ginning  of  married  Ufe,  or  has  been  noted  follow- 
ing the  occurrence  of  an\*  of  the  sy mi>t<ims  of  jxrKdc  disease. 

Physical  examination  will  reveal  all  of  tlie  anatomical  causes  and 
vaginismus. 

STERILITY 


I 


Sterility,  from  the  Latin  word  sterilis,  barren,  meaning,  when 
jqipHiHi  to  a  woman,  that  she  has  not  Ix-irne  a  living  child, — not  that 
•he  is  unable  to, — is  classified  as  ahmlute  (primary)  f<ieriliiy  wherf* 
no  child  has  lHX?n  bonie  and  no  miscarriage,  or  no  abortion  has 
taken  pla<!c,  as  relatii^e  (secondary)  sterility  where  one  or  more  preg- 
nan«*i<'s  have  occurml,  followed  by  a  j.»eri(xi  of  un  fruit  fulness,  or  foe- 
utUiliveHieriJity,  infeiiility  caustMl  by  the  prevention  of  conception. 

Sterility  may  be  due  either  to  the  husband  or  to  the  wife,  possibly 
to  lx»th,  therefore  no  physician  should  submit  a  woman  to  local 
trt^atnient  for  sterility  without  first  assuring  himself  that  the 
husband*!*  organs  of  proc*rt*ation  are  functionating  normally.  This 
is  done  by  questioning,  by  an  examination  of  the  penis  and  testicles, 
and  by  a  microscopical  examination  of  semen  spent  into  a  glass 
vial,  wliich  is  then  eorke<l  and  kept  warm  at  the  lx>dy  tempeniture, 
hy  placing  it  in  warm  water.  Questioning,  not  in  the  presence  of 
the  wife,  will  determine  whether  the  man  thinks  that  coitus  is 


148  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

performcMl  normally,  or  whether  he  has  noticed  any  abnormality  of 
his  generative  organs,  or  has  had  gonorrhea.  Examination  of  the 
penis  an<l  testicles  by  the  physician  may  detect  some  anomaly  that 
the  patient  had  not  susp(»cted: — it  may  show  a  gleety  mx^thral 
discharge.  Microscopical  examination  of  the  semen  on  a  warm 
slide  will  show  whether  it  contains  living  spermatozoa  or  not. 
Care  must  be  exercised  not  to  heat  the  l)ottle  containing  the  s(mi(?n 
too  much  or  to  let  it  get  cold,  or  the  si)ermatozoa  may  be  killed. 

Sterility  in  the  Male 

The  frequency  with  which  the  fault  li(»s  with  the  husband  in 
cases  of  sterility  is  obviously  a  matter  difficult  to  determine.  San- 
ger, and  Lier  and  Ascher  (quotcnl  l)v  K(»lly,  ''Medical  Gynecology'') 
have  studied  this  matter  in  a  number  of  cases.  Of  242  husbands  of 
sterile  marriages  (^xaminexl  by  these  authoi-s,  104,  or  43  per  cent, 
showed  absence  of  living  spermatozoa,  or  deficiency  of  semen  and 
imi)otency,  the  proportions  being,  resi)ectively,  79  cases,  and  25 
cases.  Further,  55  of  the  men  had  infected  their  wives  with 
gonorrhea,  pro< luring,  as  the  authors  assume,  indirect  sterility. 

A  fair  infcTence  from  tlu\<i*  statistics,  by  three  competent  observ- 
ers^ is  that  in  sonu^thing  over  half  of  the  sterile  marriages  the  fault 
lies  with  the  husband,  hence  the  importance  of  investigating  the 
man  as  well  as  the  woman. 

Steuility  i\  Women 

Age  as  a  Factor. — As  pointed  out  by  Matthews  Duncan  and  shown 
in  the  following  table,  the  age  at  marriage  is  the  chief  factor  in  the 
expectation  of  sterility. 


Arc  at  Marriage. 

15-PJ 

4:5.7 

2(>-24 

2r>-29 

30-34 

35-39 

40-44 

45-49 

Perc<'iitagc  of  wives  bearing  a 
child  within  two  years  .... 

90.5 

75.8 

62.9 

40.9 

15.4 

..3 

From  this  it  will  I>e  seen  that  fecundity  is  greatest  in  women 
who  have  Ix'cn  married  Ix't  ween  the  ages  of  twenty  and  twenty-four, 
and  decreas(\<  progressively  until  the  menopause. 


STERILITY 


149 


I 


Duiieuii  hsfi  shown  also  l»y  his  statiHtirs  that  of  the  wives  marritHl 
l>ptwe«*ii  the  ages  of  twenty  and  twenty-four  who  wvrv  all  ft^rti!**, 
ojily  fsix  hikI  two-t«^iiths  [)(*r  tTnt  In'^aii  to  Ix'ar  aftrr  thn^e  yi^ai-^ 
of  niarriHgc\  In  other  words,  wht^n  the  ('X|>cctation  of  fertility  is 
grt'ate^st  the  question  of  i>rol>ahlr  sterility  is  soonest  <lf*fiiled. 

The  age  of  the  wife  has  a  lx»aring  on  sterility,  for,  atTording  to 
this  same  author's  statisties,  the  following  percentages  were 
ob^rvtHl:^ — 


AfleofWiVfa»t 

1&-19 

20-24 

25-20 

30-34 

3A-39 

40-44 

46-49 

SOmuI 
ow. 

Totml. 

Number  of  wive* 

ob^rved 

Sterile  wives...  J 
Percentage  sterile 

700 
51 
7.3 

J. 835 
0 
0 

1,120 
311 
27.7 

402 

151 

37.5 

206 

109 
53.2 

no 

100 
90.9 

46 

44 
95.6 

29 

29 
100 

4,447 
725 
16.3 

Other  Factors.^Tlie  factors  essential  for  proereation»  as  far  as  the 
woman  is  concemetl,  are,  the  presence  of  a  living  o\Tam,  a  healthy 
endoinetrium  upon  which  the  o\^nn  may  develop,  i>ennealjiljty  of 
the  genital  tract  so  that  tlie  spermatozoon  may  reach  the  ovum, 
anci  wcretlons  of  the  genital  tract  that  ai*e  not  inimical  to  the  life 
of  the.  spermatozoon,  or  that  do  not  bar  its  upward  progress  to  the 
ovum. 

Entninee  of  the  penis  into  the  vagina  is  not  necessary  to  produce 
eonce[>tion,  for  cases  are  on  record  Avhere  pregtiancy  has  occuritHl, 
and  women  have  come  to  la(^M>r  even,  with  an  unruptured  hymen 
which  prei^nte«l  oidy  a  nimute  oiiening;  therefore  deposition  of 
semen  on  the  \'ulva  is  all  that  is  ntM'essary  in  some  cases.  Also, 
sexual  feeling  is  not  a  nect-ssity,  ffir  women  have  eonceivnj 
nfter  intercourse  while  unconscious  from  intoxication  and  othcT 
eausc^^  and  artificial  insemination  has  proiluced  conception.  Still, 
conception  \s  rnort*  likely  to  occur  if  the  penis  enters  the  vagina  and 
if  sexual  ftx'lings  with  an  orga^sm  are  present,  the  spermatozoa,  in 
all  proliability,  fintUng  a  more  ready  entrance  to  the  uterine  cavity 
fluring  the  orgasm. 

I-ea\ing  out  of  accoiuit  the  ^luestion  of  age.  already  considered, 
the  following  may  h^  enumerated  as  rauses  of  sterility  in  wotnen: — 
(1)  Ban*  to  conception  in  the  form  f>f  atromalit:^  and  diseases  of  the 
uterine  organs.  (2)  Conditions  of  the  uterine  organs  caui?ing 
interruption  of  pregnancy  and  death  of  the  fertilize*!  ovum  or  fetus 


150  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

(abortion  and  cxtra-iiterinc  prcgnancy),  an(i  (3)  CJonstitutional 
diseases  and  general  causes  acting  either  in  preventing  conception, 
or  in  terminating  it  after  it  has  begun. 

1.  Anomalies  and  Diseases  of  the  Uterine  Organs. — ^The  following 
is  a  list  of  the  pelvic  diseases  commonly  found  associated  with 
sterility,  beginning  with  the  vulva  and  ending  with  the  ovaries: — 

Imperforate  or  rigid  hymen  (preventing  penetration). 

Tumors  of  the  vulva  (preventing  penetration). 

Urethral  caruncle  (dyspareunia). 

Absence  or  atresia  of  the  vagina  (preventing  penetration). 

Vaginismus  (preventing  penetration). 

Vaginitis  (destruction  of  spermatozoa  by  discharges,  especially 
gonorrhea). 

Rupture  of  the  pelvic  floor  (allowing  semen  to  run  out). 

Inversion  of  the  vagina  with  uterine  prolapse  (preventing  in- 
semination). 

Infantile  uterus  (lack  of  normal  endometrium). 

Anteflexion  of  the  uterus  (mechanical  obstruction,  together  with 
endometrial  discharges). 

Endometritis  and  polypi  (abnormal  endometrium  and  discharge). 

Erosions  of  the  cervix  (spermatozoa  barred,  or  killed  by  dis- 
charge). 

Lacerations  of  the  cervix  (spennatozoa  barred,  or  killed  by 
discharge). 

Cancer  of  the  cervix  and  body  (spermatozoa  barred,  or  killed 
by  discharge). 

Fibroids  of  the  uterus  (unknowTi  direct  cause). 

Hyperin volution  of  the  uterus  (abnormal  endometrium). 

Nodular  and  obliterating  salpingitis  (very  frequent  cause, 
especially  of  one-child  sterility.  Canal  of  tube  obstructed  by 
nodules  or  closed  by  adhesive  inflanmiation). 

Under-development  or  atrophy  of  the  ovaries  (oophoron  of 
ovary  afi'ected,  so  that  healthy  ova  are  not  produced,  or  are  not 
thrown  off). 

Ovarian  tumoi*s  (all  of  functionating  oophoron  destroyed,  or 
ova  can  not  reach  tubal  ostium). 

Adhesions  about  the  ovaries  (same  as  ovarian  tumors). 

2.  Conditions  of  the  Uteri7i€  Oryans  that  Cause  Interruption  of 
Pregnancy. — ^The  chief  local  causes  of  abortion  are: — 


Pelvic  congestion  from  excessive  roitus. 

Endometritis  (abiionual  endoinetriuin). 

Retrodisplacements  of  the  uterus  (preventing  tlir  progressive 
enJargcrnent  of  the  uterus)* 

Uircmiions  of  the  cervix  (through  endometritis  and  lack  of 
protection  of  the  ovum  or  fetus). 

Syphilis  of  the  pluet'ota  or  decidua. 

Introduction  of  foreign  borlies,  sueh  as  catheters,  into  the  uterus. 

Follicular  salpingitis  (funnshhig  diverticula  for  the  ilevelopment 
of  extra-uterine  gestation). 

3.  Const Uutioriai  Diseases  and  General  Causes.— The  chief  con- 
stitutional affections  that  either  cause  failure  to  conceive,  or  in- 
terrupt pregnancy  are: — 

The  acute  diseast^s,  especially  the  infectious  diseaaes,  such  as 
acute  rheuniatisni^  scarlatina^  and  typhoid  fever. 

Alcoholism  and  morphinism. 

Sypliilis  (frequent  cause.  From  sy(>hiHs  of  plac-enta  and 
deciilua,  or  transmittiHl  from  father  tlirou^h  s^pmeu). 

ExccHsjve  ob^ity^  occur  ring  rapit  Uy. 

Anemia,  associatecl  with  chronic  heart  disease,  kidney  disease, 
dial)etc*s,  or  tulxTculosis, 

The  psychosi^s  (mental  (:hs<?ases  or  sudtlen  nervous  shocks). 

Inbreeiling  fmamage  of  cousins). 

Masturlmtion  (chronic  pelvic  congestion  from  conjugal  onan- 
isaif  simple  masturbation,  or  douches).  • 

VESICAL  SYMPTOMS 


The  chief  symptoms  of  disease  or  derangement  of  function  of  the 
urinary  organs  are: — 

(1)  Difficult,  retarded,  or  painful  urination,  dymria, 

(2)  To«)  frequent  urination, /re^we^ii  miciuriimi, 

(3)  Incontinence  of  urine,  enuresis, 

(4)  Retention  of  urine,  ischuria. 

(5)  Suppression  of  urine,  anuria. 
I,  Dysuria,   from    the   Greek  words,  ^'Ji%  ill,  and  oupu,^  urine, 

ies  an  inulnlity  to  start  the  stream  and  to  empty  the  i)ladder, 
Jso  pain  attending  the  act  of  mictiu-ition.     When  the  urine 
ttptised  drop  by  drop  with  spasmodic  pain  the  condition  is  known 


152  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

as  strangury  (from  (frpdy^^  a  drop  and  ohpov^  urine).  It  is  found 
in  cystitis,  especially  in  those  forms  of  cystitis  that  are  due  to 
poisoning  by  cantharides  or  turpentine. 

Painful  or  difficult  urination  is  a  very  common  symptom  com- 
plained of  by  women  who  suffer  with  gynecological  affections. 
Some  authors  estimate  the  number  of  such  women  who  have  vesical 
symptoms  as  high  as  one-half  of  all  the  cases  applying  to  the 
physician  for  relief.  A  greater  or  less  degree  of  dysuria  ahnost 
invariably  accompanies  pelvic  inflammation  and  also  gonococcus 
infection,  but  more  of  this  later. 

The  physician  will  do  well  to  rule  out  first  the  general  constitu- 
tional causes  of  dysuria.  Pain  and  burning  during  urination  may 
be  due  to  a  too  acid  or  too  concentrated  urine.  This  is  the  case  in 
patients  who  habitually  ingest  a  small  quantity  of  fluids  and  also 
in  lithemic  women.  Sometimes  this  symptom  is  indicative  of 
acute  nephritis,  because  then  the  urine  is  concentrated.  The 
ingestion  or  absorption,  through  the  lungs  or  skin,  of  turpentine 
may  cause  dysuria,  and  in  the  same  manner  cantharides,  mustard, 
and  pepper,  when  taken  internally  or  applied  to  the  skin,  may  be 
attended  by  this  bladder  symptom. 

The  local  causes  of  dysuria,  beginning  at  the  meatus  urinarius, 
are,  urethral  caruncle  (see  Chapter  XXIII.,  page  453).  Here  the 
pain  may  be  so  severe  that  the  nervous  system  is  upset  and  the 
patient  becomes  melancholic.  The  pain  is  described  as  ''scalding," 
''stabbing,''  "shooting,''  or  "cutting,"  and  is  felt  while  the  urine 
is  passing  over  the  caruncle  and  for  some  little  time  afterward. 
The  pain  is  a[)t  to  be  aggravated  during  the  menstrual  period,  and 
the  dread  of  the  pain  is  often  so  great  that  urination  is  deferred  as 
long  as  possible,  so  that  retention  may  result.  In  many  of  these 
cases  there  is  a  constant  pain  in  the  vulva  as  well  as  the  pain  which 
attends  micturition,  the  constant  i)ain  being  aggravated  by  walking. 

Dyspareunia  generally  accompanies  dysuria  in  these  cases,  and 
there  may  be  bleeding  on  coitus. 

Urethritis  is  due  in  a  great  majority  of  cases  to  gonorrhea  and  is 
a  common  cause  of  dysuria.  Anything  that  increases  the  con- 
gestion of  the  pelvic  organs,  such  as  menstruation  or  pregnancy, 
(exaggerates  the  inflammation  of  the  urethra,  and  therefore  increases 
the  severity  of  the  symptom  of  difficult  or  painful  micturition. 
(See  Chapter  XXIII.,  page  450.) 


VESICAL  S^IPTOMS 


153 


Dovmivard  disl4}caii<m  of  the  urethra  is  a  not  infrequent  cause  of 
lUflieulty  in  i>a.ssin|:  urine,  ami  so  y  stricture  of  the  urethra,  one  of 
the  mnult!?  of  un'tluitts.  Suburethnd  uhsvess  ^viwraWy  cau-ses 
clilficulty  in  urinatioTu  It  i.s  a  subacute  diseaMe  ami  is  attenLled  by 
j)ain»  fever^  ilyspareimia,  and  the  intermittent  ilischarges  of  pus. 

The  eausi^  of  dysuria  that  are  situated  in  the  hiaililer  are: — 

(a)  Caladi  and  foreign  bodies,  whieh  are  ui^ually  attended  by 
e>n^ttis;  {h)  cybtitis  in  its  various  fonns  (see  Clmpter  XXI\\^  i>age 
462);  and  the  (c)  new  gronih^  of  the  bladder ,  the  most  frequent  of 
which  are  papilloma  and  cancer, 

a.  Too  Frequent  Urination* — The  time-worn  term  '^irritable 
bladder"  lias  ^ivcn  way  to  a  more  rational  ant  I  more  exaet  descri}> 
tion  of  both  the  sjiriptoms  and  the  pathological  eoriditions  present. 
To  esiabli.^h  the  fact  of  tw>  fre(|uent  urination,  tlie  phyj^ician  nuist 
inquire  a^s  to  the  patient's  habit  as  regards  emptying  the  bladder. 
Many  women  are  accustomed  to  void  urine  only  at  long  intervals 

tinie,  pt^rliajjs  once  or  twice  a  day.  Perhaps  tliey  ingest  very 
ill  quantities  of  fluids.  Under  the  influence  of  excitement ^  of 
Jaking  more  Huitls,  or  of  cold,  the  amount  of  urine  may  Ik*  larger, 
ad  the  desire  to  pass  it  consequently  more  pressing  and  more 
rn*quent.  On  the  other  liand,  a  small  amoimt  of  fluid  taken  by 
the  mouth  and  aliundant  jiei^piration  will  liiminisli  the  amount 
of  urine  secreted,  and  ther€4ore  the  necessity  for  passing  it. 

Inquiry  into  too  frerjuent  urination  should  deal  with  the  custom 
of  the  individual  undtT  ordinary  conditions  of  health.  How  many 
times  t)y  day,  anti  how  many  tiriii:s  by  night.  Tuo  frequent  urina^ 
tion  must  be  differentiated  from  ineontuience,  and  this  will  be 
tnken  up  in  the  s4H:tion  nn  iurtiidinence. 

Mcjst  comlitions  which  make  nueturition  painfid  also  cause  it 
to  Ix^  too  freciuent.  Tliis  is  the  case  with  the  inflammations  of  the 
pelvic  organs.  Here  we  are  considering  only  the  affections  which 
are  cliirfly  <listinguished  by  abnormal  frequency. 

Ihirimj  pretjmmeij  \\\v  urethra  and  the  ne<*k  of  the  bladder  partake 
€>f  the  congi^stion  of  all  the  ix*lvic  organs  at  this  time.  Why  this 
congestion  of  the  neck  of  the  bladder  is  attends  I  by  too  fi*e(|uent 
miclurition  in  some  pregnant  women  and  not  in  others  we  do  not 
know, 

Tlie  statemc*nt  may  Ix^  made  ihat,  as  a  general  rule,  micturition 

more  frecjuent  during  [tregnancy,  espt^cially  during  early  preg- 


154  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

nancy,  than  at  oIIkt  times.  AVomen  who  suffer  with  uterine 
disease  may  have  too  frecjuent  micturition  only  at  the  time  of 
menstruation  because  of  the  additional  congestion  of  the  neck  of 
the  bladder  at  that  i)erio(l. 

The  ingestion  of  large  quantities  of  fluids,  especially  of  those 
which  have  a  diuretic  effect,  like  tea,  coffee,  and  beer,  is  followed 
by  frequent  micturition,  so  also  are  diabetes  mellitus,  diabetes 
insipidus,  and  hysteria,  Ix^cause  of  the  secretion  of  an  abundant 
supply  of  urine  in  these  disc^ases. 

Urethritis  aiid  stricture  of  the  urethra  are  causes  of  frequency, — 
even  congenital  smallness  of  the  meatus  may  cause  frequency. 
Contracted  bladder,  by  not  permitting  any  considerable  quantity  of 
urine  to  accumulate,  causes  frequency,  and  so  do  tumors  of  the 
bladder  situated  in  the  neighborhood  of  the  vesical  trigone. 

Cystitis  is  attended  by  increased  frequency  of  micturition,  in 
fact  it  is  a  cardinal  symptom,  but  there  are  no  data  in  hand  to 
show  that  increased  frcijuency  is  due  to  ureteral  or  kidney  disease 
where  the  bladder  is  not  at  the  same  time  affected,  although  put 
from  a  suppurating  kidney,  in  the  same  manner  as  concentrated 
urine, — perhaps  containing  cr}''stals, — may  stimulate  the  bladder 
neck  and  cause  freciuency  of  urination,  also  the  passage  of  a  renal 
calculus  along  the  ureter  may  cause  a  reflex  desire  to  urinate.  The 
bladder  is  so  frequently  involved  in  cases  of  pyelitis  and  ureteral 
calculus,  however,  that  frequency  of  urination  may  be  considered 
a  symi)toni  of  those  diseases. 

3.  Incontinence  of  Urine  (Enuresis), — 1.  Ia)co1  Causes. — Inability 
to  control  the  escape^  of  urine  from  the  bladder,  or  the  passing  of 
it  unconsciously,  may  be  due  first  of  all  to  an  overdistended  bladder. 
In  this  event  the  urine  escapes  a  little  at  a  time  and  the  patient 
may  not  realize  that  the  bladder  is  overfilled;  her  complaint  being 
only  that  her  clothes  are  wet  or  that  she  can  not  control  the  urine, 
permanent  incontinence  exists  in  v(*sic()-vaginal  fistula,  also  in 
vesico-utorine  and  uretero- vaginal,  or  uretero-uterine  fistula.  (See 
Chapter  XXIV.,  page  474.) 

Incontinence  is  a  feature  in  epispadias,  downward  dislocation 
of  the  urethra,  and  in  some  cases  of  prolai)S(^  of  the  uterus,  and  in 
cystoccile.  In  the  latter  cases  the  urine  may  escape  only  when  the 
intra-abdominal  pressure  is  increascnl  in  laughing,  coughmg,  sneez- 
ing, or  straining. 


I 


VESICAL  SYMPTOMS 


155 


I 


2.  (ieneral  Causes,— Nociurnal  enurefffs  is  a  form  of  uicontineticr 
found  in  tvliildrerh  llviv  large  t|uantitit'8  of  urint*  are  voided,  quite 
uncon8ciou.sly,  at  night  only,  the  aflfeetion  being  supposefl  to  be 
caused  by  an  over  reflex  excitability  of  the  nervous  mechanisn^i  of 
the  bladder.  Rarely  a  local  abnoriiuility,  such  as  aji  a^Uaereiit 
prepuce,  may  act  as  a  cause. 

Incontinence  may  be  due  to  a  dlsonhT  of  th*-  lirain  itself  (a),  or 
(b)  to  some  affection  of  that  j lortion  of  the  spinal  cord  which  puts 
the  brain  mto  communication  with  the  vesical  centers  in  the  sacral 
flegments  of  the  cord. 

(a)  Tlie  conditions  whieli  inhibit  conscious  cerebral  acti%ity  aret 
coma,  from  whatever  eause^  as  alcohol,  ejjilepvsy,  or  cerebral  hem- 
orrhage; some  insanities;  sunstroke;  shock,  and  the  poisons  of 
some  of  the  infectious  diseasc\s,  as  diphtheria  and  typhoid  fever. 

(/»)  The  lesions  w^hich  interfere  with  the  conduction  bt^tween  the 
lirain  and  the  vesical  centres  in  the  lower  cord  are:  myelitis, 
injuries  and  tumors  of  the  cord,  spinal  meningitis,  and  locomotor 
ataxia. 

If  the  reflexes  are  entirely  alx)lished  total  paralysis  of  the  bladder 
with  retention  and  dribbling  of  urine  ensues;  if  the  paralysis  is 
partial,  there  will  be  partial  retention,  with  occasional  voiding  of 
urine  and  it^  involuntaiy  escape  after  voluntary  urination  is 
finished*  The  last  happening  is  a  frefjuent  occmTcnce  in  locomotor 
ataxia* 

4.  Retention  of  Urine  (Ischima). — The  urine  may  he  retained  in 
the  bladder  and  the  patient  unable  to  void  it  in  the  same  diseases 
of  the  brain  and  spinal  cord  as  in  the  case  of  incontinence  just 
noteil.  It  is  a  pretty  constant  symptom  of  multiple  sclerosis. 
Retention  often  alternates  with  incontini»nce  in  cases  of  coma 
and  the  typhoid  state.  Iletention  is  conunoo  m  hysteria^  and  in 
order  that  ovcrdistention  of  the  bladdc-r  may  be  avoidetl,  tlif^ 
physician  should  palpate  and  p«'rcuss  the  ]ow*i-  alidomen  of  the 
hysterical  woman  to  detect  a  full  bladder.  Retention  is  not  un- 
common during  late  prexpiancy,  and.  whatever  the  cause,  may  result 
in  a  lack  of  expelling  power  and  atony  of  the  bladder.     Retention 

to  bt*  expected  in  inmrcemikm  of  the  reirofJexed  pregnant  utenis^ 

d  may  occur,  rather  infrecjuently,  in  fibroids  and  o\'arian  tumors. 
Retention  1ms  occurred  bc*cause  of  blocking  of  the  urethra  by  a 
suburt*thral  abscess,  or  by  cancer  of  the  lu'ethra.     Temporary  re- 


156  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

tention  has  been  caused  by  the  occluding  of  the  urethra  by  a  cal- 
culus or  a  i)edunculateil  tumor  of  the  bladder,  and  lodgment  of  a 
stone  in  the  ureter  may  produce  n»tention  by  causing  spasm  of  the 
s{)hincter  vesicae. 

5.  Suppressi<Hi  of  Ac  Urine  (Anuria). — If  urine  is  not  secreted,  or 
if  secreted  does  not  reach  the  bladder,  the  condition  is  known  as 
suppression  of  urine,  or  anuria.  The  catheter  must  be  passed  and 
the  bladder  found  empty  before  anuria  may  be  said  to  be  present. 

Anuria,  a  rare  condition,  may  occur  in  hysteria,  in  uremia,  during 
the  terminal  stage  of  chronic  nephritis,  in  acute  nephritis,  or  in 
poisoning  by  turpentine,  lead,  phosphorus,  or  cantharides.  Sup- 
pression of  urine  has  been  noted  in  yellow  fever,  typhoid  fever,  and 
the  late  stages  of  acute  yellow  atrophy  of  the  liver,  and  in  sunstroke. 

In  hysterical  anuria  the  diagnosis  is  established  by  passing  the 
catheter  and  then  repeating  the  procedure  after  a  definite  interval 
of  time, — say  two  hours,  when  the  patient  does  not  expect  it, — 
thus  obviating  conscious  or  unconscious  malingering.  If  both 
ureters  are  obstructed  by  disease  within,  or  by  pressure  from  with- 
out (see  Chapter  XXV.,  page  489),  so  that  no  urine  reaches  the 
bladder,  the  condition  is  kno\\Ti  as  obstructive  anuria.  This  is  a 
rare  condition,  the  diagnosis  being  made  by  cystoscopy  and  ure- 
teral catheterization. 

RECTAL  SYMPTOMS 

In  taking  the  history,  certain  facts  pointing  toward  rectal  disease 
are  to  be  noted;  among  them  are  the  occurrence  of  slight  morning 
diarrhea,  continuing  over  a  long  period  of  time  and  alternating  with 
attacks  of  constipation,  a  sense  of  weight  in  the  pelvis,  dull  pain 
in  the  region  of  the  sacrum,  and  pain  or  swelling  of  the  left  lower 
limb. 

Pain. — As  to  pain,  ask  when  it  was  first  noticed,  the  exact  situa- 
tion, how  long  the  attack  usually  lasts,  what  effect  has  defecation 
upon  it,  and  how  severe  it  is.  The  most  probable  cause  of  pain 
occurring  over  a  long  period  of  time  is  fiasure.  When  of  recent 
occurr(»nce,  i)ain  may  be  (hie  to  fissure,  complete  fistula,  blind 
internal  fistula,  or  i)rolaps(Ml  internal  piles.  If  the  pain  is  in  the 
anus  the  chances  are  that  tlie  l(\^i()n  is  there,  whereas  if  it  is  in  the 
region  of  the  sacrum  the  lesipn  is  ])rol)ably  in  the  rectum  proper. 


FECAL  SYMPTOMS 


I 


If  the  pain  last^  after  ^lefccation  for  several  hour?,  the  [irolmhio 
diagnosis  i^  fissuj^e  or  blind  internal  fi:?tula,  or  L-oniplete  ftstnla  w itli 

largo  internal  ofx^niiig.  Pain  t'eaj^rs  after  defecation  in  the*  ease 
bf  .stricture,  but  bi  the  ca.se  of  piles  the  pain  iK*rsi»ts  a.s  long  as  the 
piles  are  outside  the  sphincter. 

Pain  folJowing'defeeation  indicates  fissure,  blintl  internal  fistula^ 
proIa|>S(*d  internal  piles,  or  a  |>rotryc|pd  polypus  or  tunior.  Pain 
aeeonipanying  constJi>ation  and  nOieved  only  l>y  ein))tying  the 
rectum^  is  jjrobablydue  to  inipaetion  of  feces,  ulceration*  or  stricture. 
Pain  or  itching,  coming  only  after  the  jiatient  has  gone  to  be<l,  may 
mean  external  piles  or  eczema  about  the  anus. 

Hemorrhage. — Hemorrhage  from  the  rectum  is  either  (a)  associ- 
atoti  with  defecation,  or  (b)  it  is  indept^ndent  of  defecation. 

(a)  Bleeding  internal  piles  and  fissure  cause  loss  of  Wood  with 
the  stCKils.  When  the  feee^s  passed  are  only  smearrd  with  a  little 
blood,  the  diagnosis  may  be  ulcer  of  the  rectunK  Profuse  hernor- 
rhage  sfmietinics  accomparues  diiecation  in  the  eajsiMif  internal  jiiles, 
a  slight  hemorrhage  Ix^ing  more  usual  in  cases  of  prolapse,  polyp,  f>r 
\illous  tumor. 

(b)  Hemorrhage  inde(x*ndent  of  defecation  occurs  in  some  caf*f»s 
of  internal  pil<^s,  cancer,  and,  in  the  case  of  prolapsjMl  growths,  in 
prolapse  of  the  nmcous  membrane,  in  internal  jnles.  and  in  polyp. 
Continuous  hemorrhage  seldom  lasts  more  than  twenty-four  hours 

F^and,  as  a  rule,  hemorrhage  in  rectal  disease  is  intermittent.  Blood 
may  come  from  the  skin  around  the  anus  in  the  ease  of  eczema, 
fissurcni,  external  piles,  or  tulierculosi.s  in  that  region. 

Rectal  Discharge, — Besides  blooil,  there  may  be  discharged  from 
the  rectum,  mucus,  nuicopus,  anrl  serous  fluid.  An  increase  in 
the  amount  of  the  rectal  nmcus  is  found  in  proctitis,  in  internal 
piles,  in  prolajise,  and  in  stricture  with  invagination  of  the  rectum. 

In  the  case  of  elir<:)nic  hypertro|ihic  [proctitis  the  amoimt  of 
mucus  passed  jmt  anuni,  often  involuntarily,  is  so  gn^at  that  the 
[tutient  is  forccnl  to  wear  a  najikin.  Pus  is  due  to  an  uljsc(»ss  which 
ha»  ruptiUTfl  into  the  bowel,  or  to  a  fistula-in-ano,  Muco-pus  is 
generally  found  in  ulceration,  whether  malignant  or  simple. 

Serous  fluifl  is  passim!  in  cases  of  villcKis  tumor,  often  in  large 
rjnantitic^  and  involuntarily.  Besides  making  inquiry  on  these 
painti«  the  patient's  linen  should  Imt-  uisjM>cteib 

Fecal  AccumuJatian,— The  rectum  is  almost  always  found  fillec! 


158  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

with  feces  in  cases  of  fissure,  internal  piles,  eczema  of  the  anus,  and 
hjTXjrtrophy  of  the  external  sphincter  from  whatever  cause.  In 
the  case  of  stricture  of  the  rectum  the  accumulation  of  feces  will  be 
found  above  the  stricture,  not  below.  The  symptoms  of  this 
condition  may  lx»  nothing  more  than  a  sense  of  fulness  in  the  rectum, 
or  there  may  be  no  sjTnptoms.  Digital  examination  makes  the 
diagnosis.  The  physician  should  have  the  probabilities  in  mind 
before  making  the  examination. 

Difficulty  in  Defecation. — ^\Vith  this  condition  there  is  present  a 
more  or  less  constant  desire  to  empty  the  bowel,  and  defecation  is 
not  attended  by  relief.  It  is  not  the  same  as  constipation.  If  the 
dread  of  going  to  stool  is  due  to  pain  caused  by  the  act,  the  probable 
diagnosis  is  fissure,  or  ulcer,  or  a  partly  torn  off  polj^),  causing 
spasm  of  the  sphincter.  If  there  is  a  tightness  of  the  sphincter, 
the  muscle  will  be  found  hypertrophied  and  non-dilatable.  If  there 
is  much  pain  with  straining  bc^fore  and  during  defecation  and 
disappearing  entirely  aftcT  defecation,  leaving  a  sense  of  only 
partial  reli(*f ,  a  stricture  is  probably  present. 

Character  of  the  Feces. — Diarrhea  is  not  a  true  diarrhea  unless  it 
consists  of  a  frequent  discharge  of  fecal  matter,  whether  solid,  semi- 
solid, or  fluid.  True  diarrh(»a  is  not  frequently  met  with  in  rectal 
disease.  If  the  feces  are  passed  in  short  pieces  of  small  caliber,  with 
a  little  mucus  and  blood,  or  pus  and  blood,  a  stricture  is  probably 
present.  If  there  is  much  blood  and  the  feces  are  not  in  small 
pieces,  cancer  is  to  be  suspected.  In  prolapse  or  invagination  of 
the  rectum,  the  fec(*s  are  apt  to  be  scybalous. 

Protrusion  from  the  Anus. — This  occurs  in  internal  piles,  polyp, 
and  pedunculatiHl  tumors,  including  villous  tumors  and  cancer.  If 
the  protrusion  is  associated  with  defecation,  the  tumor  returning  to 
the  n^ctum  spontaneously  soon  after, — the  probable  diagnosis  is 
internal  piles,  a  polyp  with  short  pedicle,  a  moderate  degree  of 
prolapse,  or  a  villous  tumor.  Wh(»n  the  protrusion  remains  down  for 
several  houi-s,  the  probable  diagnosis  is  internal  piles  which  have 
become  pe(lunculat(»d,  a  polyp  with  long  pedicle,  a  marked  degree  of 
prolapse,  or  a  villous  tumor,  and  also,  if  protrusion  occurs  on  stand- 
ing or  straining,  it  is  probably  duo  to  an  extreme  degree  of  any  of 
these.  The  afl'ections  referred  to  in  the  preceding  section  will  be 
fomid  described  at  length  in  Chapter  XXVI.,  pages  498,  and 
523-525. 


OOCX^VGODYNIA 


159 


COCCYGODYNIA 


I 
I 


The  tc*nn  coceyi50<lyuia  (from  zoxx'j^^  coccyx,  and  «>'^>vr^,  pain) 
is  the  name  given  by  Sir  James  Y.  Simpson  to  pain  in  the  Region  of 
the  coecyx,  an  affection  (XTurring  almost  entirely  in  women  and 
jjc^nerally  chie  to  injiu'v  of  the  coccyx  during  lalxjr.  Some  time 
^rev'ioiii*  to  May,  1844,  Di\  J.  C,  Nott,  of  Mobile,  Alalmma,  removed 
the  last  two  coccygeal  lx>nes  in  a  young  unmarried  woman  for 
'^neuralgia  of  the  co<Tyx/'  dut^  to  caries  of  the  coccyx^  following 
injurj^  from  a  falJ.  This  is  the  first  recorded  instance  of  co(*cy- 
godjiiia,  which  is  very  commonly  associated  with  g>Tiecological 
affections. 

Coccygc^hnia  may  occur  in  men  when  due  to  iujmy,  but  it  is 
extrrnuly  rare.  As  in  Xott  s  ca.-^^,  the  disease  in  woman  may  be 
aseociated  with  caries  of  the  bone;  this  is,  however,  rare,  and  the 
pathological  apI^earanc(^s  of  the  specimens  removed  by  operation 
show  mast  often  disi^asr*  of  tlie  joint  bf^tween  tiie  first  anil  s<.*cond 
coccygeal  bones.  The  thive  lowTr  bones  aix?  genemlly  ankyloses 
in  adults  so  that  forcing  them  backwanl, — as  in  labor, — or  forward, 
ns  in  a  fall  on  the  buttocks  when  the  tbiglis  are  fl(^xcNl^  places  the 
strain  on  the  ordy  movable  joint,  tliat  Ix^tween  the  first  and  secontl 
piecf«.  Besides  injuiy  ro  the  joints  the  coccyx  may  be^  fractmtHl, 
The  etiology  of  the  pain  is  obscure  and  some  authors  attribute  it  to 
rheumatism  of  the  muscles  in  the  neigliborhood  of  the  coccyx, 
others  to  sprains  of  the  ligaments,  and  still  others  to  some  affection 
of  Lushka's  coccygeal  gland,  wliich  has  a  rich  nerve  supply. 

The  i?\*mptoms  consist  of  continuous  pain  in  the  region  of  the 
coeejic  aggniVHtCH^l  by  sitting  down  and  by  rising  from  a  sitting 
postun?.  A  hard  seat  causes  especially  severe  pain  and  pain  is 
exaggerated  by  defi»cation  and  by  coitus.  Mild  cases  are  fairly 
common,  but  severe*  ones  are  infrecpient.  In  the  bad  eases  thei*e 
may  b*.'  constant  pain  along  the  eiilire  hnigtii  of  the  spinal  colunm; 
the  patient  may  get  up  from  a  sitting  pasture  by  placiing  the  palm 

one  hand  uix>n  the  seat  of  the  chair  and  the  other  on  any  con- 
^letiient  support,  and  pashing  the  IknIv  up  by  the  anns  as  much  tis 
possible^  so  as  to  avoid  t-nntracting  the  muscles  of  the  pehic  floor 
and  the  glutei.  The  bad  casoe  are  usually  the  victims  of 
netiraflthema. 


160  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

In  making  the  diagnosis,  tenderness  of  the  eoecyx  to  light  pres- 
sure, both  froni  the  skin  surface  and  by  a  finger  in  the  rectuni,  is  the 
chief  feature.  If  there  is  dislocation  the  lower  bones  of  the  coccyx, 
grasped  between  the  finger  in  the  rectum  and  the  thumb  in  the 
crease  of  the  nates,  may  be  thrown  out  of  line  with  the  upper  bone, 
or  bones.  A  fracture  may  be  felt  as  a  ridge  on  the  surface  of  the 
coccyx. 

Tenderness  over  the  cocc)rx  by  both  vaginal  and  rectal  digital 
examination  may  be  found  in  proctitis  (see  Chapter  XXVI.,  page 
5()6),  therefore  in  establisliing  the  diagnosis  of  coccygodynia  this 
disease  must  be  ruled  out. 


PRURITUS  VULV^ 

Pruritus  vulvae,  or  itching  of  the  \iilva,  is  a  S3rmptom  which 
may  be  the  source  of  a  great  deal  of  misery  to  its  victim,  and  may 
lead  to  serious  derangement  of  the  health  from  loss  of  sleep  and 
constant  nervous  irritation.  In  the  severe  grades  it  is  often  accom- 
panicKl  b^  evidences  of  impairment  of  the  nerv^ous  system,  such  as 
frec^uency  of  micturition,  indigestion,  irritability  of  temper,  and 
instability  of  disposition.  It  is  a  symptom  and  is  undoubtedly 
due  to  a  certain  sort  of  irritation  of  the  terminal  filaments  of  the 
nerves  in  the  skin  of  the  vulva,  but  the  pathology  is,  as  yet,  unknown. 
The  causes  of  pruritus  may  be  divided  into:  (1)  irritating  dis- 
charges from  the  vagina  or  bladder,  (2)  diseases  of  the  vulva,  and 
(3)  neuroses. 

I.  Irritating  discharges  from  the  vagina  are,  (a)  leucorrhea  from 
chronic  endometritis.  Leopold  holds  that  this  is  a  very  common 
cause  of  i)ruritus;  also  leucorrhea  from  vaginitis,  as  in  gonorrhea, 
is  a  not  uncommon  cause  of  itching. 

(6)  The  urine  of  diabc^tes  is  a  frequent  cause  of  pruritus.  The 
patient  complains  of  groat  thirst,  drinks  large  quantities  of  water, 
and  is  hungiy  most  of  the  time.  Examination  of  the  vulva  shows 
slight  redness  about  the  orifice  of  the  urethra,  rechiess  and  perhaj)s 
induration  of  the  labia,  and  excoriations  from  scratching.  The 
urine  has  a  sweetish  smell  and  on  examination  is  found  to  contain 
sugar.  Pruritus  is  often  the  fii-st  symptom  which  leads  to  the 
diagnosis  of  diabetes. 


(c)  The  urine  of  cystitis,  or  nephritis,  may  cause  pruritus,  but 

Ithis  is  not  a  eoninion  haiJiMiiing  and  usually  yields  readily  to  treats 
'nient  for  the  urinary  ilifFirnlty. 

3.  Diseases  of  the  vulva  rausing  pruintus  are,  first,  (a)  congestion 
of  the  vulva  and  varix  of  the  vulva,  botli  commonly  found  in  preg- 
nancy, in  uterine  or  ovarian  tumors,  or  in  any  ol>stru(*tion  to  the 
vt.*nous  nj^tmii  of  the  bItXMl  in  th<^  pelvis,-— sufii  as  intra-abdominal 
pressure  on  the  vena  cava.  Even  the  congestion  of  the  menstrual 
pctriod  may  be*  accompanitxl  by  it(*hing. 

(fc)  Vulvitis  and  kraurosis  vulvae  are  attended  by  more  or  Ic^ss 
pruritus,  the  latter,  generally  by  mtense  itching. 

(r)  Pediculus  pubis  is  a  cause  of  itching.  On  careful  inspection 
of  the  hairs  of  the  \qilva  the  parasites  or  their  nits  are  rea^lily  seen 
and  are  de.stroyt^l  by  shaving  the  parts  and  ancinting  witli  a  ten- 
per-cent  solution  of  carbolic  acid  and  olive  oil. 

(rf)  Thrush  of  the  \iilva  is  a  cause  of  pruritus,  and  in  httle  girls 
(e)  simple  uncleanliness  seems  to  operate  as  a  cause,  (/)  Eczema 
of  the  Milva  is  nearly  always  attended  by  severe  itching. 

3,  Neuroses.^ — Untler  this  head  we  may  hiclude,  (a)  ma^turha- 

Ition,  although  it  is  doubtful  whether  the  itching  is  not  the  cause  of 

f  the  masturbation,  rather  than  the  reverse.     There  can  bt^  no  iloubt, 

however,  Imt  that  constant  handling  and  irritation  of  the  clitoris 

and  vulva  make  for  hypersensitiveness  and  therefore  exaggeration 

of  a  predisp^isition  to  pnu'itus. 

(b)  Oxyuris  vermicularl*^,  or  pin-worms,  found  in  the  rectum  in 
children,  cause  itching  not  only  alx)Ut  the  anus  but  of  the  vulva 

In  finiritus  vulvie  in  a  child  this  cause,  as  well  as  uncleanli- 
s,  should  Ix'  always  souglit  fur. 

(c)  Pruritus  is  conmion  at  the  menopause  without  discoverable 
lesions  of  the  vulva ^  and  is  observed  sometimes  also  in  (d)  women 
having  a  rheumatic  diathesis. 


n 


PART  II 

SPECIAL   DIAGNOSIS 


CHAPTER   XI 


THE   DIAGNOSIS   OF   ENDOMETRITIS,    INCLUDING 

GONOHRHHA    AND    EROSIONS  OF  THE 

UEHVIX    UTERI 

Aiuitomy  and  [ihysiology  of  the  efidoiuelrium,  p.  166, 
Pathology,  p,  HJJK 

Aniiiowiico-piilhological  chissifiealioii.  p.  170, 

Endunietrifis  from  a  diiiical  point  uf  view,  p.  17!l:  Acute  non -gonorrheal 
rndonietfitis,  p.  173:  Etiology,  p,  173;  S>^Tlptoms,  p,  I7i;  Signs,  jk  17ti. 
Ulironic  non-gimorrheal  endotne Iritis,  p.  170;  Varieties,  p.  176,  (1)  Of 
puerperal  origin,  or  [)ost-ttlMjrtiirn,  p.  176,  (2)  Those  varieties  which  are  not 
prectxled  by  a  known  acute  stage,  p.  177;  Etiology,  p.  177;  Symptoms, 
p.  177;  Signs,  p.  178.  Gonorrheal  endometritis  and  gonocoerns  infii'tion, 
p.  171i,  Acute  gonorrheal  endometritis,  acute  gonorrheal  emlocervifitis,  p. 
180;  S^TTiptoms,  p.  181,  Diagnosis,  p.  181,  Differential  diagnosis,  [j.  IHl; 
Chronic  gonorrheal  endoinetrilis,  p.  18*?:  Ljitent  gonorrhea  in  women, 
p.  182;  Differential  diagnosis  of  chronic  gonorrheal  endometritis,  p.  1H,*1. 
Senile  endometritis,  p.  IKK  Endoc*ervidtis,  p.  184.  Erosions  of  the  (^rvix 
uteri,  p.  184:  Characteristics,  p.  184;  Diagnosis,  p.  185;  Differential 
diagnosis,  p.  186. 

Alihough  endoiuetritls  is  a  part  of  tlic  inflammatory^  process 
callc^l  Pelvic  Inflanimation,  it  oiay  exint  without  involvement  of 
the  i>eriiit^rine  stnicture^,  A»  pelvic  inflamniation  is  most-  often 
rau.sf*il  by  infection  introduced  thnjugh  the  vagina  and  utcms,  so 
endometritis  is  generally  a  Ix-ginniiig  stagi*  of  pelvic  inHanimation. 
Tlie  term  endmneiritis  will  \w  used  to  define  inflaiimmtioa  of  the 
endometrium. 

Entlocervicitis  is  the  name  given  to  the  inflamnmtory  process 
whi*n  it  is  liniitetl  to  thf*  cervix.  The  flilTerentiation  of  endocer- 
vicitis  from  enilometritis  of  the  body  has  a  i>ractica]  importance 
in  the  acute  infections,  es|)CTially  m  gonococcus  infection ,  and 
abo  in  the  chronic  form  of  inflainntation  wherry  the  disease  is  aj^t 
to  be  situatfHl  chiefly  in  tlie  rervical  canal  An  inflammatory 
prcxreas  Httuated  in  the  entlometrium  may  c»xtend  to  the  muscular 
i?tructurc  of  tfie  uterus,  and  then  the  process  may  Ix'  defined  more 
tly  as  a  metritis. 

In  practice  the  diagnosis  of   metritis  aside  from  endometritis 

165 


166 


THE  DIAGNOSIS  OF  ENDOMETRITIS 


is  an  academic  affair  and  of  no  practical  significance  even  when 
it  is  possible  to  diagnose  one  without  the  other;  therefore,  little 
will  l)e  said  of  metritis,  with  the  understanding  that  in  the  seven* 
grades  of  endometritis  there  is  present  also  metritis. 


ANATOMY  AND   PHYSIOLOGY  OF  THE  ENDOMETRIUM 

A  word  as  to  the  anatomy  and  physiology  of  the  endometrium 
l^efore  taking  up  the  consideration  of  the  (iiflferent  manifestations 
of  inflammation.  The  following  description  applies  to  the  un- 
impregnated  uterus  of  the  healthy  adult  woman  between  menstrual 
periods.  It  will  be  noted  that  the  mucosa  of  the  cervical  canal 
is  anatomically  and  physiologically  different  from  the  mucosa  of 

the  uterine  cavity  proper,  therefore 
we  are  justified  in  considering  the 
word  endometrium  as  applying  to 
the  latter  only. 

The  interior  of  the  uterus  is 
divided  into  two  cavities:  the  cavity 
of  the  body,  and  the  cavity  of  the 
neck,  which  are  separated  from  each 
other  l^y  the  constricting  ring  of 
muscular  tissue  about  the  internal 
OS.  The  shape  of  these  cavities  has 
been  referred  to  elsewhere,  the  cav- 
ity of  the  l>ody  being  represented  by 
an  inverted  isosceles  triangle  with 
the  two  angles  of  the  base  in  the 
uterine  cornua  and  the  third  angle 
at  the  internal  os.  The  anterior 
and  posterior  walls  of  the  uterus 
meet  at  the  sides  at  an  acute  angle  so  that  there  are  no  lateral 
walls  i)roi)er,  therefore  the  uterine  cavity  is  flattened  from  before 
backward.  The  cervical  cavity  is  fusiform  in  shape,  largest  in 
the  middle  and  contracted  at  the  internal  and  external  ora. 

Under  resting  conditions  the  cavity  of  the  body  is  closed  against 
infection  from  Ik'Iow  at  the  internal  os  and  from  infection  from 
above  by  the  muscular  constrictions  at  the  isthmuses  of  the  Fallopian 
tubes.    The  cavity  of  th(?  ccTvix  in  like  manner  is  protected  from 


Fig.  64.  —  Reconstruction  of 
Uterus,  Showing  Shape  of  Uterine 
Cavity  and  Cervical  Canal.  (Wil- 
liams.) 


ANATOMY  AND  PHYSIOLOGY 


IGT 


mfection  from  above  by  the  narrowing  at  thu  inttTnal  o.s,  and  frurn 
below  in  the  nullipai'oiLs  uterus  more,  and  in  the  parous  uterus 
less,  by  the  conslrietion  at  the  external  o8. 

The  wall  of  tlie  uterus  is  niarle  up  of  thi'ee  layer's,  the  thin^  serous, 
jx^ritoneal  layer,  the  tliiek  iimscular  layer — oom|>o8ing  most  of 
the  structure  of  the  uterus — and  the  rnodium  thick  mucous  layer. 
The  mucous  layer,  the  endonietrium,  eonsists  of  the  utricular 
glauils,  connective  tissue,  blao< I- vessels,  nerves,  and  lymphatics.  It 
is  covered  by  a  single  layer  of  ciliatcii  columnar  epithelium — which 
aJso  lines  the  glands — and  is  coutinuetl  through  the  Fallopian  tubes. 


^  V''^-'-?=  ^cA 


5^. 


Fio,  65,— Normal  Eodometrium, 


(WUliams.) 


The  endometrium  is  essentially  a  glandular  structure.  The 
glanris  arc  tubular  and  branching,  several  opening  often  by  one 
mouth.  They  extend  into  the  muscular  layer  and  all  o[»en  into  the 
^Uterine  cavity.  In  the  bo^ly  of  the  uterus  tlie  endometrium  Is 
rifjecly  united  to  the  muscularis,  whereas  in  the  neck  it  is  fn^er. 
In  the  cervix  uteri  the  lining  epithehum  shades  into  pavement 
epithelium  at  the  external  os.  In  this  cavity  the  mucous  mem- 
brane Is  thrown  into  olJique  ridges  which  diverge  from  an  anterior 
and  posterior  longitudinal  ra|)he,  presenting  an  appearance  which 
has  received  the  name  of  arl>or  vitse. 


168  THE  DIAGNaSlS  OF  ENDOMETRITIS 

The  normal  secretion  of  the  uterine  glands  is  a  clear,  watery 
fluid,  having  an  alkaline  reaction,  that  of  the  glands  of  the  neck  is 
clear  and  viscid;  it  is  also  alkaline.  Throughout  the  cervical 
mucosa  are  found  a  variable  number  of  little  cysts,  presumably 
glands,  which  have  become  occluded  and  distended  with  retained 
secretion.  They  are  called  the  ovula  Nabothi,  or  Nabothian 
follicles. 

The  endometrium  shows  normally  many  differences  in  structure 
from  infancy  to  old  age  and  during  the  intermenstrual  and  menstrual 
cycles. 

Before  puberty  it  is  relatively  thin  and  undeveloped,  nearly  all 
of  it  having  the  character  of  the  cervical  mucosa. 

Our  views  as  regards  the  normal  histology  of  the  endometrium 
have  of  recent  years  undergone  a  considerable  change,  due  to  th(» 

important  observations  of  Hitschmann  and 
Adler  {MonaU^sclmft  fur  Geburts.  und 
GynaekoL,  1908,  XXVII.,  1),  confirmed 
by  several  subse(iuent  investigators. 

Hitschmann  and  Adler,  after  a  painstak- 
ing study  of  the  uterine  mucosa  from  fifty- 
eight   women  at  various  periods  of    the 
,,      ^^     A7-    •    1  17  *         menstrual  cycle,  found  that  the  endome- 

tio.  bb. — Virginal  Extcr-  '^       ' 

nal  Os.  (Williams.)  trium  from  the  c(\st<ation  of  one  menstrual 
flow  to  that  of  the  next,  presents  a  con- 
stantly changing  histological  picture.  This  cy(!le  of  changes  they 
divide  into  four  phases;  postmenstrual,  interval,  premenstrual, 
and  menstrual.  At  the  height  of  the  menstrual  flow  the  nmcous 
membrane  diniinish(\s  in  thickness  and  the  glands  pour  out  their 
secretion,  l)econiing  narrow  and  straight.  The  surface  epithelium 
is  freciuently  lost,  but  this  is  not  an  invariable  rule.  After  the 
period  th(T(^  takes  place  a  very  rapid  cell  growth  in  both  the 
epithelium  and  connective  tissue.  The  glands  Ix^come  larger  and 
wider,  although  still  quite  narrow  and  straight.  The  epithelium 
is  low  and  in  a  condition  of  rest.  By  about  the  fifteenth  day  the 
cell  growth  of  th(^  e{)itheliuni  has  progressed  to  such  an  extent  that 
the  glands  bcH'ome  somc^wliat  tortuous,  and  often  assume  a  spiral 
or  corkscrew-like  app(*arane(\  Finally,  six  or  seven  days  before 
the  l)eginning  of  menstruation,  the  glands  rapidly  enlarge  and 
be(»ome  tortuous,  the  colls  Inilge  into  the  lumen,  the  epithelium 


>  w 


PATHGIOGY 


im 


becomes  higher  antl   broatler,   ami   thv  luiucii   is   filled   with   a 

mucous  secretion.    Thcise  gland  changes  are  much  more  marked 

in  the  dee[HT  jK>rtioii  of  tlie  nuicosn  than  in  the  superficiah  su  that 

there  is  produced  a  well-marked  differentintioo  into  a  suiierfieial 

rompaet  and  a  deep  spongy  layer.     In  this 

respect   there  is  a  marketl   t^imilarity  to 

the  ap[>earanee  of  the  young  decidua,  thi^ 

resemblance   lx*ing  increa.sed   by  the  fa(*t 

that    the  mterglandular   stromal  cells  in 

many  cases  assume  an   a]>pearance  very 

similar  to  or  approaching  that  of  decidual 

cells. 

During  pregnancy  the  mucosa  of  the  cor- 
pus uteri  is  enormousiy   congested.      Its 

function  is  the  formation  of  the  deeidua — the  connectives  tissue 
cells  of  the  endometrium  going  to  make  the  decidual  celk  of 
pregnancy* 

Following  the  menopause  there  is  an  atrophy  of  the  endometrium 
coiuciiient  with  th«"  sluinking  of  the  uterus  so  that  in  the  old 
woman  the  uterine  glands  are  foimd  almost  t  ntin^ly  obliterated, 
And  there  is  apt  to  lx»  partial  or  complete  closure  of  the  uterine 
canal  at  the  internal  as. 


Fig.  66a.— Parous  Exfer 
nal  Os.     (Williams,) 


PATHOLOGY 


It  is  probable  that  all  forms  of  endometritis  are  due  to  bacterial 
invasion  of  the  endometrium.  The  endometrium  under  normal 
conditions  is  sterile,  and  bacteria  in  small  numlx»rs  introduced 
from  without  are  promptly  destroyeil.  Although  clR-mical  irrita- 
tion and  trauma  may  cause  congestion  and  favor  bacterial  growth, 
the  idea  that  these  influences  and  ** constitutional  taints''  do  any- 
tiling  more*  than  provifle  a  fertile  sfiil  for  the  microorganisms  has 
gone  the  way  of  many  older  theorie^s. 

The  following  l>act^ria  have  Ijeen  found  in  the  endometrium  in 
cases  of  endometritis — seldom  in  pure  cultures,  generally  in  mixetl 
infections:^ 

Staphylocwcus  pyogenes  albus,  citreus,  and  aureus. 

Streptococcus  pyogenes, 

Gonococcus. 


170  THE  DUGNOSIS  OF  EXDOMETRITIS 

Colon  l)acillus. 

Tulx^rclo  bacillii?. 

Diphtheria  l)acillus. 

Typhoid  l>accilliis. 

Pneumococcus. 

Bacillus  aerogenes  eapsulatus. 

Spirochivta  pallida  of  syphilis. 

In  many  forms  of  cndomotritis  the  bacterium  reaches  the  endo- 
metrium from  without  by  way  of  the  vagina;  in  a  smaller  number 
of  varieties  it  comes  from  the  Fallopian  tulx^s  or  abdominal  ca\'ity 
through  the  lum(*n  of  the  tulx*s:  and  in  still  other  varieties  it  conies 
through  the  lymphatics  and  veins  of  the  uterine  wall  from  near-by 
sources  of  uifection  in  ix^ritoneum,  rectum,  or  bladder:  and  rarely 
it  reaches  the  endometrium  from  distant  sources  through  the  blood 
current. 

The  classification  of  endometritis  has  long  been  a  stumbling 
block  to  the  gj-necologist.  A  recent  writer  on  the  subject  gives  a 
pathological  classification  containing  eleven  different  forms,  accord- 
ing to  the  macroscopic  or  microscopic  ap|)earances  of  the  different 
varieties,  and  a  clinical  classification  of  ten  different  sorts  of  clironic 
endometritis. 

A  l)acteriological  classification  will  ultimately  Ix*  the  one  chosen 
as  a  guide  to  diagnosis.  At  pr(\^ent,  not  enough  facts  are  known 
to  justify  its  use.  As  it  is  im|)os>il)le  to  diagnose  the  different 
varieties  according  to  the  pathology,  except  by  examination  of 
scrapings  from  tlu*  endometrium,  and,  according  to  the  presc*nt  state 
of  our  knowledge  of  th(»  pathology  of  the  endometrium,  the  differ- 
entiation of  th(^  varieties  has  no  Ix^aring  on  the  treatment,  we  shall 
consider  tlu^  subject  from  the  (»Iinical  point  of  view.  Suffice  to 
mention  the  forms  of  (endometritis  which  have  been  recognized  as 
a  result  of  the  micr()sc()|)ic  examination  of  scrapings  and  of  uteri 
removed  by  operation. 

ANATOMICO-PATHOLOGICAL  CLASSIFICATION 

Hypertrophic  endometritis ^  in  which  the  endometrium  is  thickened 
and  soft.  If  the  glands  are  incn»ased  in  size  only,  it  is  called 
hyjKrtrophic  cjlamhilar  emlotnetritis^  if  they  are  increased  in  number 
it  is  called  hyperplastic  glandular  endometritis. 


AN  ATOM  WO-  PAT  HUH  Xi  ICA  L  TLAHS I FICAT  ION 


171 


F.  Hitsehniann  ami  I.,  AdltT  (ZeU.  f.  (kbs,  il  Gun,,  19U7,  LX., 
63)  gtate  timt  (^ndoinrtritis  glaiMlularis  hyiM-rtrophira  ami  ciuI<h 
niPtritin  ^landiilaris  hv[MTpIaHtica  have  nothing  what80i*vcr  to  ilo 
with  inflaiiynatioii.  The  hrst  Is  not  cvvn  a  |>HtlioloKit'al  contlition  cif 
thr  ntrrin**  rnurosa  hut  eorro.^ponds  to  the  [^rcnionstnial  Ktatr  of  the 
nonnal  lining  of  thp  uti^ms;  the  latter  eonsist^  partly  of  the  normal 
|>renu*n.*itriial  ronditinn,  anci  |jartly  of  vaiiatiniis  in  thennrnher  of 
glancis  within  phyHiolo^ic^al  hoiits;  in  addition  it  inr hides  eases  in 
wliieh  there  in  a  glantlular  hyi*ertro|)liy  of  the  uterine  mucous 
nieinhrane,  but  thi^  ato  is  a  change  which  is  entirely  independent  of 
inflammation. 

There  i^,  accortiing  to  these  investigators,  but  one  variety  of 
inflammation  of  the  uterine  mueoisa,  endometritis  interb-titialis,  or, 
a.s  it  is  usually  ealled,  en- 
rlometritl*,  Tl le  <  I  iagt losis 
18  TLiaAle  by  demonstrating 
the  cells  of  infiltration,  so- 
eallt^!  plasma  cells. 

If  the  inflamnjator)'  proe- 
e8J*  alTt*cti5  cliiefly  the  inter- 
glandular  connt»ctive  tissue 
the  i>rt>ces8  is  kno^n  as  in- 
terstiiiat  endometrium.  This 
fonn  lias  an  acute  and  a 
chronic  Ftagc,  the  acute 
lR*ing  characteriztMl  by  dif- 
fuiio  or  circumscribed  infil- 
tration of  tlic  stroma  by  small  round  cells  with  congesftion  of  the 
l>loo<l-ve8H<»ls  and  a  serous  exutlate  in  the  spaces  of  the  connective 
tissue  (exudative  interstitial  endometritis).  Tlie  chronic  stage  Is 
cliaracterized  by  newly  fornKsl  connective  tissue  resulting  in  com- 
[m-siqon  of  the  utricular  glands,  and,  in  the  later  stages  in  atn*pliy 
t>f  tlif»enc!ometriimit  theso-cidled  atrophic  cmioffietriii^'i. 

Retention  cysts  may  \w  fomu^d  in  the  interglandular  spaces  of  the 
connective  tissue  and  ri/fitir  interstilial  endometritis  results,  or  the 
glarals  may  Ix*  oljstructec!  by  the  (>res><ure  of  the  connective  tissue 
at  their  mouths,  cyf^tic  i/landulnr  efidfnnctritis,  Fungoii>(  endome- 
triiiM  \»  the  term  appliiHl  when  tl»e  uiucosa  is  thrown  into  folds; 

Uqu»  endontetriiis,  when  it  in  covered  with  shaggy  villosities;  and 


Vui.    G7.  —  Horizoutai  Sectkiii    of    the  Tp- 
p<.vr  Part  of  the  Body  of  tlie  Utenis. 


triurn — as  in  carcinoma  and  tuberculosis— the  process  is  called 
idcerative  endojjwiritis, 

Decidnal  endometritis  is  the  name  given  to  inflanimatton  of  tho 
endometrium  during  pregnancy.  It  h  diagnot^etl  dcfinit<»ly  by 
microscopic  examination  of  the  decidua  after  expulsion  of  the  fetus. 
Evidences  of  inflammatory  action  are  present.  The  h-ymptoms 
may  Ixr  hy(h*orrhca  uteri  gravidi,  or  pains  in  the  uterine  region 
during  pregnancy. 

A  rarc^  condition  is  exfolmtive  endometritiSj  so-called  memhmnmis 
dysmenorrhea.     It  consists  of  the  discliarge  from  the  uterus  of  a 


I 


ACUTE  NON-GONORRHEAL  ENDOMETHITI8 


173 


rKn 
othi 
It  i 
tub 


more  or  less  incomplete  cast  of  the  ca\ity  of  the  corpus  uteri,  in 
the  shape  of  a  sac,  triangular  in  form,  gray  in  color,  and  of  a  rough 
surface.  Floated  in  water  and  laid  open,  its  interior  is  smooth. 
When  examined  undrr  a  nm^^nifyuig  glass  it  is  seen  to  Ix;  .studded 
with  minute  openings  \vhi(*h  rrpresc^nt  the  mouths  of  the  utricular 
glands.  \\Tieji  the  sac  is  reaisonably  complete  the  openings  of  the 
Fallopian  tub€\s  may  \yc  rlistinguished  at  the  upi>er  angles  of  thi* 
hae.  The  membrane  is  from  one  to  three  millimetei-s  tli!<'k  ancl 
under  the  microt^'oix^  shows  much  the  appearances  of  exudative 
ifiterstitml  endomeiritw^  although  the  pathological  appearances  vaiy 
in  different  cases, 

Tubertulom  emlmneiritiH,  relatively  rare,  is  a  sequel  often  of 
primary  tuberculosis  of  the  tulxs.  Rarely  it  is  primary  in  the 
eemx.  TuIktcuIous  infection  may  rencli  the  endometrium  also 
from  without  by  coitus,  or  ljy  instrumental  or  digital  interference. 
Occurring  in  the  late  stages  of  general  tutxrculous  infection  of  the 
ito-urinary  system,  it  has  no  clinical  im[X)rtance,  tx^causf*  the 
'other  manifestations  of  the  disease  are  of  overshmiowing  seriousness. 
It  i^  characttTized  by  the  prt^sence  of  giant  cells,  tulxTcles,  an*! 
tubercle  bacilli  fomid  microscopically  in  scrapings  made  from  the 
endometrium.  The  tulxTcle  bacilli  may  Im*  detectefl  in  the  uterine 
dL^harges.  Many  cover-slip  pivparations  ishould  bt^  studied  before 
affirming  the  absence  of  the  bacnllus. 

Not  much  is  kno\^Ti  of  tlie  forms  of  endometritis  occurring  after 
the  acute  infectious  dis<*a.ses^typhoid  fever,  diphtheria,  scarlet 
fevcT,  measles,  and  smallpox — nor  of  the  endometritis  which 
attendi*  syphilis. 

Gonorrheal  endometritis  will  be  con.sideretl  separately  under  the 
eljBJeal  clarification. 


ENDOMETRITIS  FROM  A  CLmiCAL  POIIfT  OF  VIEW 

The  subject  Is  b<'st  divided  into  nrule  and  chronic  eiidometrilis^ 
with  sjM^cial  coi»sideration  of  (jonorrheal  endometritis,  sefiile  endmne- 
iritis,  and  endoceTriritis. 

ACITTE   NOX-OONORRHEAL   ENDOMETRITIS 

Etiology.— This   is   an    inflammation    due   to    inva^sion   of  the 

idometxiuiu    by  septic    microfirganisms,    more    especially    the 

lylococcuB    and  the  streptococcus.     It  is  a  grave  form  of  en- 


174  THE  DUGXOSLS  OF  ENTX)METRm3 

(lonietritls  a^  eontra.<tcil  w\xh  a  majority  of  the  chronic  forms  of  en- 
riometritis,  wliich  are  of  a  miki  tj-pe  and  have  no  recognizable 
acute  stage. 

lx<  chief  caase:?  are:  i  1 1  infection  following  labor  and  abortion; 
(2;  the  a<e  of  uncleanly  fingers  or  instruments  in  making  office 
treatments:  «3)  oiH»rations  which  are  not  aseptic,  and  (4)  sloughing 
intra-uterine  tumors. 

(1)  Infection  following  lal)or  and  abortion  is  the  most  frequent 
cause  of  acute  endometritis.  It  can  not  be  entirely  avoided  even 
with  the  most  scnipulous  can*.  Retaineil  membranes  may  de- 
compose and  cause  it.     Too  often  the  phj'sician  is  to  blame. 

Bacteria  brought  to  the  vagina  .on  carelessly  washed  hands,  lack 
of  thoroughnc^ss  in  the  preparations  for  the  immediate  repair  of 
the  injuric^s  of  the  jX'lvic  floor  and  piTineum  following  labor,  the 
unn(M;e.ssar>'  use  of  forceps,  or  too  fret[uent  vaginal  examinations, 
to  say  nothing  of  too  much  doucliing — thereby  washing  away 
the  nonnal  si»c»rt*tions  of  the  vagina,  which,  according  to  Doder- 
lein  destroy  pathog(»nic  l)acteria — all  play  an  important  part. 
The  great  danger  of  so-call(\l  s<'ptic  endometritis,  which  attends 
criminal  alx)rtion,  is  tfx)  well  known  to  re<[uire  extended  comment. 

(2)  The  general  practitioner  of  mcnlicine,  realizing  the  necessity 
of  washing  his  hands  after  an  examination,  is  cart»less  about  washing 
them  Ix'fore  making  a  vaginal  examination  or  instrumental  treat- 
ment. The  practice  of  making  intra-uterine  office  treatments  is 
dangerous  even  with  strict  asepsis,  Ixsides  lx*ing  useless  as  a 
therapeutic  measure.  Passing  the  sound  into  the  uterine  cavity 
should  Imj  done  only  under  strict  aseptic  precautions  and  iiith  the 
utmost  gentleness  to  avoid  trauma. 

(3)  Minor  operations  may  cause  as  great  harm  as  major  ones  and 
too  commonly  do  so  Ix'cause  tlu*  preparations  for  the  lesser  pro- 
cedures are  not  as  can^fully  made. 

(4)  Sloughirig  of  a  uterine  polyp,  of  a  pedunculated  submucous 
fihroid,  or  of  an  inverted  uterus  sometim(»s  results  in  septic  endo- 
metritis unless  prompt  oju'rative  measures  are  instituted. 

Symptoms. — TIk*  symptoms  of  acute  endometritis  with  septic 
absorption,  acute  .vc/>//r  ettdonietriti.'^,  manifest  themselves  within 
twenty-four  to  forty-eight  hours  after  hif(H*tion,  although  they  may 
be  delayed  for  several  days.  Their  severity  depends  uix)n  the  form 
of  infection.     A  septic  intoxication  which  is  due  to  the  absorption 


ACITTE  NON^ONORRHEAL   ENDOMETRITIS 


175 


iiiio  the  system  of  ptomames, — the*  product  of  decomposition  set 
up  by  bacteria, — is  calkxl  mpremm;  that  wliieh  is  due  to  the 
alisorption  of  the  bacteria  themselves  with  their  toxins  is  known  as 
^seiduefnia  |irojx*r.  As  yet  vv(*  have  no  nit'ans  of  drtcirnining  wiiich 
form  of  infection  is  prt^ent  in  any  given  eas(^  We  know  that  the 
form  caust^d  by  th**  streijtoeoecus  is  the  more  grave,  that  the 
streptococcus  may  Ix-  chfTustMl  very  rapitlly  throughout  the  system, 
ttud  that  in  dt*ath  irsuhing  from  this  form  tliere  may  h(*  found  few 
pathc»logical  changes  in  the  iK*lvic  organs.  The  staphylococcus,  on 
the  otlifr  hand,  is  more  aj^t  to  jiroihiee  marked  loral  ren<'tion  and 
pus  formation.  The  severity  of  the  symptoms  will  vary  acconhng 
to  the  eontirmcHl  presence  of  the  soiux'c  of  infection  anti  the  rat>idity 
of  its  al^sorption.  Although  the  endometrium  is  the  point  of  en- 
trance of  tlie  infective  material  into  the  system  and  endometritis 
is  the  first  manifestation  of  the  poisoning,  tlie  tlisease  is  a  general 
one  almost  from  the  first,  In  the  later  stages  of  the  disease*  the 
involvement  of  tissues  neiglilM>ring  to  the  endometrium — the  uterine 
tnui^cle,  p<»lvic  cellular  tissue,  the  Fallopian  tubes,  ami  peritoneum — 
produces  complications  which  overshadow  the  enilometritis.  The 
symptoms  are  ushered  in  by  a  st*vere  chill,  followed  by  elevation 
of  temj>erature  (103°-1(H°  F.  or  higher),  and  a  rapid  pulse  (lllK 
120  or  higher).  If  the  disc^asr  follows  labor  or  abortion  the  lochial 
di^harge  is  diminishtnl  in  amount  at  fin?t  and  then  increat*ed,  tH> 
comes  dark  in  color,  tiien  [>mHilent,and  generally,  though  not  in  the 
.stn^ptococTic  form,  has  an  offensive  cxlor.  If  the  disease  tloes  not 
follow  Ialx>r  or  al>ortion  a  blf>o<ly,  purulent,  usually  offensive  uterine 
di.scharge  is  a  constant  symi)tom  after  the  initial  chilJ.  Intermitti'iit 
uterine  pains^ — tjeeoming  eontiimous  and  sev<vre  if  the  inflammatory 
proc«?ss  nmches  the  peritoneum— naus4^^*a,  const ii>at ion,  and  freiiu**nt 

tWtU  painful  micturition  are  early  symptoms. 

Irregularly  ix'<Hirring  chills,  high  temix^rature,  rapid  and  fet^We 
pulse,  a  sensi'  of  welMxing  and  apathy,  the  eliaracteri.stic  un- 
dt??scrifx*<l  cnlor  of  s4L*psis,  iliarrhea,  and  failing  strength, are  symi)tonis 
of  the  advanced  stages  of  the  disease. 

AmU;  tridorftetritis  iritlntuf  mjfremia  or  tn'idiceffiia,  is  attended  l»y 
comparatively  slight  constitutional  distiu'lmnces  and  the  syirijjtonis 

'lUv  linuti*il  to  elevation  of  temjXTature — generally  pnvtnled  by  a 
cliill— pain  of  mo«lerate  s<:verity  in  the  lower  alMlomen,  fre*juent 
and  painful  micturition,  nausea,  and  disturbance  of  menstruation,^ 


176  THE  DLVGNOSIS  OF  ENDOMETRITIS 

either  suppression  or  menorrhagia.  The  symptoms  abate  in  a  few 
days. 

Signs. — In  all  forms  we  find  on  physical  examination, — ^the  uterus 
enlarged  and  soft,  tender  to  light  pressure  in  all  parts;  the  vagina 
hot  and  dry;  the  uterine  discharge  wanting  at  first  and  later 
mcreased  in  amount.  The  os  is  patulous.  Rigidity  and  tenderness 
of  the  abdominal  muscles,  called  peritonismus,  is  to  be  expected 
if  the  peritoneum  is  involved  in  the  inflammatory  process,  other- 
wise not.    Acute  endometritis  without  complications  is  uncommon. 

If  the  case  is  seen  early  an  anesthetic  should  be  given  because  of 
the  great  pain  caused  by  manipulation.  Thorough  aseptic  precau- 
tions are  observed.  A  sound  is  passed  into  the  uterus  and  retained 
membranes,  or  sloughing  tumors,  polypi,  or  fungosities  are  detected 
by  sound-touch.  In  cases  of  doubt  the  cervix  should  be  dilated 
until  it  will  admit  the  operator's  finger,  and  the  interior  of  the  uterus 
explored  by  touch,  all  adventitious  tissue  being  removed  either 
with  the  finger,  curette,  or  curette  forceps,  and  preserved  in  a  ten- 
per-cent  formalin  solution  for  microscopic  examination. 

Chronic  Non-gonorrheal  Endometritis 

Varieties. — Chronic  endometritis  may  be  divided  into:  (1)  those 
forms  of  acute  endometritis  that  have  terminated  in  a  chronic  form, 
and  (2)  the  varieties  w^hich  present  no  acute  stage  demonstrable 
by  clinical  methods. 

(1)  The  forim  of  acute  endometritis  which  have  become  chronic  are 
commonly  of  puerperal  origin,  or  postnibortum.  Some  of  the 
pathological  varieties  are, — pscudodiphtheritic,  decidual,  and 
ulcerative  endometritis.  A  chronic  endometritis  resulting  from 
an  acute  s(*i)tic  endometritis  generally  has  as  complications  one  or 
more  of  the  following  affections: — metritis,  cellulitis,  peritonitis, 
pelvic  abscess,  or  salpingitis.  When  the  inflammatory  process  is 
centered  (chiefly  in  one  of  the  situations  just  enumerated,  the  in- 
flammation of  the  (endometrium  is  less  active  and  the  physical  signs 
indicate  that  in  the  endometrium  the  fire  has,  as  it  were,  burned 
out,  leaving  only  smouldering  embers.  Microscopic  examination  of 
the  endometrium  n^veals  one  or  more  of  the  different  stages  of 
glandular  and  interstitial  endometritis  as  described  on  pages  170 
and  171. 


CHHONIC  NONMIONOHEHHAL   KNDOMETRITIS 


177 


If  st^ptiecmia  is  present  the  .syTiiptoins  are  those  of  dironic 
L6c*pticeiiiia;  fluctuating  rlcvations  in  the  tenitieraturej  rapitl  and 
feeble  pul.se,  (U-y  i^kiii,  diarrhea,  the  oilor  of  sepwis,  niahiutrition,  and 
anorexia. 

There  being  no  septieeniia  the  symptoms  are  leueorrliea^  uterine 
heruorrhage*s,  rneni^trual  di.sturi)anees»  dyspareunia^  t^terility,  antl 
|abr»rtinn,  and  .symj>toni8  referable  to  the  digestive  and  nervous 
rstems. 

I^ticorrhea  is  the  oidy  constant  symptom.  The  discharge  is 
profuw<% — though  varying  in  amount  in  individual  causes.  It  is 
purulent  in  character  and  may  be  mixed  with  blood.  It  is,  as  a 
rule,  odorless  urdess  it  has  Ix'en  retained  on  the  vulva  and  has 
iIeconi[>os4*<l  IxTause  of  the  jiatient's  uneleardy  hal>its. 

A  liistoiy  of  an  acute  attack  of  septic  infection  and  the  character 
of  the  leucorrhea — e^jx^cially  if  septic  mirrourganisms  can  be 
found  in  it  u|)on  microscopic  examination  of  cover-glass  prepara- 
tions— servT  to  distinguish  tliis  furni  of  imtlometj'itis  from 

(2)  The  large  number  of  varieties  of  chronic  endometritis  which  are 
not  preceded  by  a  hunim  acute  stage.  They  may  Ix*  enumerated 
iBs: — fungous,  villous,  polvix>id,  exfoliative,  and  tulxTculous. 

The  endometritis  of  the  infectious  diseases — tyfihoid  fever, 
diphtheria,  scarlet  fever,  measles,  small-pox,  and  syphilis— all 
arr^  of  a  mild  type. 

Etiology.— Predisposing  causes  of  chronic  endometritis  are:^ 
uterine  displacements,  uterine  malformations  (espwially  ante^ 
flexion),  subinvolution  of  the  uterus,  extensive  lacerations  of  the 
ueervix,  tumors  of  the  pelvis,  sexual  excesses,  chronic  constipation. 
Ihe  infectious  disc*asf\*^,  and  certain  constitutional  diseases,— anemia, 
chlorosis,  rheumatism,  and  litheniia. 

The  pathological  process<^»s  i>resent  are  glandular  and  interstitial 
endometritis  as  tlescrilx?<l  on  pages  170  and  17L 

Symptoms.— The  chief  symptom  is  leucorrhea.  The  patient  dot^s 
not  remembf^r  when  she  firsi.  noticed  a  vaginal  discharge,  so  gradual 
is  its  beginning.  It  is  due  to  the  secretion  of  the  utricular  glands 
plus  that  of  the  vulvo-vaginal  glands.  The  amount  depenils  on 
the  condition  of  the  enilometrium,^niore  when  it  is  hypertroirhieil 
and  in  the  glandular  variety  of  endometritis,  and  les*^  in  the  atrophic- 
variety.  In  tlie  fungous  ami  |Hjly|Kjid  fnnns  (he  leucorrhea  is  apt 
to  be  bloody,  and,  if  there  is  decomposition  of  tissues,  pui*ulent.  In 
12 


178  THE  DIAGNOSIS  OF  ENDOMETRITIS 

most  of  the  varieties  of  chronic  endometritis  the  discharge  is  thin 
and  serous  in  character. 

When  the  secretion  from  the  cervical  canal  exceeds  in  amount 
that  from  the  body  of  the  uterus  the  discharge  is  thick  and 
viscid  in  consistency.  It  is  without  odor  and  is  unirritating  as 
a  rule,  although  in  patients  of  uncleanly  habits  it  may  have  a 
foul  odor. 

The  amount  of  discharge  varies  from  a  staining  of  the  linen  to 
several  well-soaked  napkins  a  day;  it  is  increased  for  a  day  or  two 
just  before  and  just  after  each  menstrual  period  because  of  the 
normal  congestion  of  the  genital  organs  at  these  times. 

Hemorrhage  at  the  menstrual  period  or  excessive  menstrual 
flow — styled  menorrhagia — is  to  be  expected  in  the  hypertrophic 
form  of  endometritis;  scanty  flow  in  the  atrophic  forms.  Painful 
menstruation — dysmenorrhea — is  a  pretty  constant  symptom, 
although  it  occurs  in  such  great  variety  of  manifestations  and  at 
such  variable  times  with  reference  to  the  flow  that  it  is  impossible  to 
dogmatize  about  it.  Irregularity  in  the  occurrence  of  menstruation 
also  is  to  Ix^  expected,  variations  of  a  few  days  before  or  after  the 
normal  time  being  common. 

Sterility  and  abortion  are  more  often  observed  in  patients  suffer- 
ing from  chronic  endometritis  than  in  women  with  nonnal  uterine 
organs.  Sym{)tonis  of  gc^neral  ill  health  usually  accompany  chronic 
endometritis,  although  it  is  not  always  easy  to  determine  whether 
the  ill  health  is  due  to  the  endometritis  or  the  endometritis  to  the 
ill  health. 

Signs. — ^The  physical  examination  reveals  a  uterus  enlarged,  but 
not  necessarily  to  a  marked  degree,  and  more  or  less  sensitiveness 
of  the  uterus  to  light  pressure  when  it  is  scjueezeil  between  the  ex- 
aminer's fingers  during  the  combined  vagino-alxlominal  or  recto- 
abdominal  touch.  If  the  uterus  is  occupied  by  polypi  it  will  be  felt 
to  be  fatter  than  normal,  and  often  a  polypus,  having  been  elon- 
gated and  driven  down  b}^  the  uterine  pressure,  presents  at  the 
external  os. 

On  speculum  examination  a  discharge  is  seen  to  be  issuing  from 
the  external  os.  Its  character  is  noted.  A  tough  stringy  mucus 
is  the  characteristic  of  the  secretion  of  the  glands  of  the  cervix; 
a  thin,  watery  discharge  is  from  the  glands  lining  the  cavity  of  the 
corpus  uteri.     The  alkalinity  of  the  discharge  should  be  tested 


ENDOMETHITIS  AND  GONOCCKX'US  TNTECTrON  179 

wth  a  piece  of  litmus  paper.  In  t'ndoinetritis  the  reaction  is  often 
neutral  or  even  arid.  The  eondition  of  the  neek  of  the  uterus  is 
noteti, — whetlier  laeerateil  rjr  enxlcHl  or  not. 

On  |>a^i*ing  the  uterine  .^oiind  the  eavity  of  the  uterius  i.s  generally 
found  to  be  enlarged.  In  anteflexion  with  en<lonietriti8  the  in- 
ternal as  18  tight,  Imt  the  o|HTator  will  find  that  hy  straij^htening 

[tlM!  canal  by  traction  on  the  cervix  with  a  tenaculum  it  i.s  alway8 
Bible  to  pass  a  sound  of  small  ealilnT*,     Previous  to  passing  the 

( Founil  an  accurate  idea  should  Ix?  olitained  as  to  the  probal>le 
(liiti'tion  of  the  uterine  canal  by  means  of  the  bimanual  touch. 
Great  gentleness  i.s  esjsential 

If  the  sound  is  {>assed  witli  t!ie  greatest  care  and  blotKl  flows  after 
it**  withdrawal  and  the  cavity  is  tender,  endometritis  may  Ik* 
diagnoseil     Fnngosities  and  pt*l}'j>i  are  to  Ix*  detectwl  in  favorable 

I  caf^CB  by  the  tactile  Bensc^  transmitted  through  the  souiuh  ie.,  when 
the  canal  is  iiidely  ojx'n  and  reasonably  straight.  Points  of  ten- 
derness in  the  endometrium  and  their  definite  situations  are  deter- 

^  niltial  by  the  sound. 

GOXORRHEAL  ENDOMETRITIS   AND   GONOCOCCUS   INFECTION 

Gonorrheal  endometritis  merits  spc*eial  consideration  lx*cause  it 
^18  a  very  common  di^ai^  and  has  serious  sequehe. 

As  to  its  fn^iuency  autliors  ilo  nf>t  i^rnr.  It  is  midoid^tedly 
more  common  in  the  public  clinics  and  among  prostitutes  than  in 
private  practice.  Zweifel  estimated  that  ten  |ier  cent  of  his  private 
gynecological  cases  suffered  from  gonorrhea.  Different  WTiters 
place  gonorrhea  as  the  eaus4^  of  acute  inflannnation  of  the  uterus 
and  tubes  in  from  one-half  to  two-thirds  uf  the  patients  sc^en  in  the 
tU^Ix'nsary  st^rvices  of  the  large  cities.  Tliiif  estimate  includes 
J  some  of  the  pti(T])eral  eases,  which  form  a  considerable  number  of 
the  total  acute  infections,  for  the  gonocoecus,  as  well  ius  the  stajthy- 
lococcus  and  the  stn^i^tftcoceus^  is  the  cause  of  puerperal  infection. 

The  gonocoecus,  a  diploeoecus  diseov(Ted  by  Neisser  in  1879, 
fiiids  a  favorite  habitat  in  the  deejxT  {Kirtions  of  ihr  mucous  mem- 
bmnoH  which  are  coverc^d  with  cylin<lrical  (Epithelium.  It  also 
jrrows  n-ailily  untler  pavement  epithelium,  but  can  not  jienetrate 
the  .s<|UamoiLs  epithelium  as  easily  as  the  columnar. 

Its  favorite  homeii  in  the  female  generative  apparatus  when  once 


180  THE  DIAGNOSIS  OF  ENDOMETRITIS 

introduced  are,  in  order  of  frequency:^-(l)  the  urethra  and 
Skene's  and  Bartholin's  glands;  (2)  the  mucosa  of  the  cervical 
canal;  (3)  the  upper  portion  of  the  vagina;  (4)  the  endometrium 
of  the  corpus  uteri ;  (5)  the  mucosa  of  the  Fallopian  tubes. 

Although  the  squamous  epithelium  of  the  vagina  of  adults, 
bathed  in  its  acid  secretions  and  protected  by  its  normal  bacterial 
flora,  resists  the  invasion  of  the  gonococcus,  the  tender  vaginal 
mucosa  of  children,  although  covered  by  squamous  epithelium,  is 
easily  penetrated  by  it,  whence  the  frequency  of  vulvo-vaginitis 
among  children. 

The  gonococcus  is  speeilily  destroyed  by  other  bacteria  and  their 
toxins  in  the  case  of  a  secondary  infection  in  the  process  of  abscess 
formation,  as  attested  by  the  rarity  with  which  it  is  found  in  the 
contents  of  a  chronic  pyosalpinx;  on  the  other  hand  it  may  remain 
alive  in  the  mucosa  of  the  cer\'ical  canal  or  in  Skene's  glands  for  a 
series  of  years.  As  a  rule  gonorrheal  infections  are  uncompli- 
cated by  mixed  infections  with  other  bacteria  unless  trauma 
accompanies  the  infection. 

The  diplococcus  is  always  introduced  from  without — in  little 
children  by  the  contaminated  fingers  of  an  adult  infected  with  the 
diseases  and  by  soiled  linen  or  bath  sponges — in  adults,  as  a  rule, 
by  coitus. 

Gonorrheal  endometritis  invariably  begins  in  the  cervical  canal. 
It  may  be  liniitcMl  to  the  cervix  uteri  if  the  internal  os  is  well  closed, 
— as  in  virgins  and  in  anteflexion.  In  multiparous  women  it  is 
prone  to  spread  to  th(»  corpus  uteri.  Sometimes  the  gonococcus  is 
carried  from  the  cervix  to  the  corpus  uteri  by  the  physician's  sound 
or  uterine  applicator.    The  disease  is  acute  or  chronic. 

Acute  Gonorrheal  Endometritis 

The  disease  is  limited  to  the  cervix,  acute  gonorrheal  endocer- 
vicitis.  The  mucosa  of  the  ccTvical  canal  is  reddened,  swollen,  and 
bathed  in  pus,  which  sometimes  has  a  grei»nish  tinge.  The  neck  is 
swollen,  soft,  and  tender  to  the  touch.  Examined  histologically 
the  mucosa  shows  loss  of  (epithelium  in  places;  the  uterine  glands 
show  hypertrophy  and  liyiXMplasia,  and  the  interglandular  tissue 
is  (»normously  infiltrated  with  rounil  cells  and  polymorphonuclear 
leucocji:es.     The  blood-vessels  are  increased  in  number  and  size. 


I 


the  epithelial  t*dls  and  also  in  the  subepithelial  tissue.  The 
gonwocci  may  also  bi*  fountl  in  the  pus.  They  seklurn  penetrate 
the  utr'rine  niu.scle  hy  way  of  the  lyni|ihatics  as  do  tin*  stre|>toeoeri, 
anil  when  gonorrheal  inflaniniation  reaches  the  jx^ritoneuni  it  rloes 
8o  by  way  of  the  mucosa  of  the  corpus  uteri  and  of  the  Fallopian 
tubes. 

Symptoms. — The  symptoms  of  aeute  gonoiTheal  endocervieitis  are 
generally  marked  by  the  symi)toms  of  coineident  inHatnmation  in 
the  urethra,  vulvcvvaginal  glands,  and  vagina.  There  is  a  history 
of  inAx-tion.  The  s\inptonis  art*  ushertxl  in  by  a  ehill  followeil  by 
an  elevation  of  temptTature  and  a  ra]^id  pulse.  The  patient  com- 
plains of  pelvic  jmin,  painful  micturition  and  defecation,  nausea 
and  vomiting^  and,  in  the  course  of  a  few  hoiirs,  there  is  a  leucorrhea, 
— at  first  nnicous  in  eliaraeter,  soon  becoming  purulent  and  some- 
timi^  mixed  with  blotwL  Tlie  sym|>t(*ms  are  not  st>  severe  ws  in 
acute  septic  endometritis,  and  la.st  not  over  a  wei»k.  They  are  more 
prt>nouneiH|  if  tin*  iiiflanujiation  !ias  extended  to  the  body  of  the 
uterus,  and  still  mon*  so  if  to  the  Fallopian  tulx*s.  In  these  cases 
one  look^  for  gnmter  pelvic  and  ablominal  pains. 

Diagnosis. — The  diagnosis  rests  on  (1)  the  history  of  a  suspicious 
intercourse:*,  which  was  followeil  by  a  i>urulent  vaginal  discharge, 
and  by  prec^xling  fre<|uc*nt  and  painful  micturition,  Le.,  an  acute 
urethritis,  strong  proisumptive  evidence  of  gonorrhea:  (2)  the 
symptoms  ju5t  cmumeratcMl;  (li)  the  physical  signs.  The  cervix  is 
swollen  and  t^nrler,  and  i>us  flows  from  the  os.  If  the  nmcosa  of 
the  corpus  uteri  is  also  involved — acuite  gonorrheal  endometritis — 
the  entire  uterus  Ls  enlarged  and  tenfler  to  bimanual  touch;  (4) 
the  microscopic  examination  of  the  pus  shows  tlie  presence  of  the 
gonococcus. 

Differential  Diagnosis.— The  acute  fonn  of  gonorrheal  endome- 
tritis may  be  mistaken  for  aeute  septic  endometritis.  In  the 
^norrheal  form  the  local  anrl  (constitutional  symptoms  are  less 
Wvert*,  there  is  lacking  a  cause  for  sepsis  in  the  form  of  iJOw<t-puer- 
pcTal  infection  or  intra-uterine  treatment,  anil  on  the  other  hantl 
there  may  be  pres«nit  a  history  (»f  a  suspicious  inbTcou!*s(\  The 
urethra,  Skene's  glands,  ami  the  \ailvo- vaginal  glands  are  involved; 
thcTP  may  be  enlargement  of  the  lymphatic  glands  of  the  gnriin^ 
aflenitis^  bubo — 6iiaUy  the  gonoeot»ci  are  found  iji  the  discharge. 


182  THE  DIAGNOSIS  OF  ENDOMETRITIS 

Chronic  Gonorrheal  Endonietrilis 

Chronic  gonorrheal  endometritis  may  result  from  a  well-marked 
acute  gonorrheal  endometritis.  More  commonly  the  history  of 
an  acute  stage  is  wanting.  The  history  of  frequent  and  painful 
micturition,  either  following  marriage  or  in  a  woman  suspected  of 
having  loose  habits,  whether  married  or  single,  should  lead  the 
physician  to  consider  the  possibility  of  gonorrhea. 

The  onset  of  the  disease  is  generally  insidious;  the  symptoms 
and  physical  signs  are  those  of  the  varieties  of  chronic  endometritis 
due  to  the  saprophitic  and  pyogenic  bacteria. 

The  leucorrhea  in  gonorrheal  endometritis  is  generally  most 
abundant;  it  loses  the  purulent  character  of  the  acute  stage  and 
is  mucous  in  character.  The  diagnosis  depends  on  finding  the 
gonococcus  m  the  discharge  from  the  cervix.  Some  authors  claim 
that  it  is  necessary  to  make  cultures  in  order  to  identify  surely  the 
microorganism,  but  this  view  is  not  held  by  most.  Many  slides 
should  be  examined.  Negative  findings  do  not  rule  out  gonorrhea, 
and  this  brings  us  to  the  consideration  of  latent  gonorrhea. 

Latent  Gonorrhea  in  Women. — Certain  experiments  by  Wertheim 
of  Vienna  (Archiv.  fur  Gyn.,  1892,  XLL,  No.  1),  and  clinical 
observations  by  a  number  of  investigators,  go  to  show  that  the 
gonococcus  loses  its  virulence  after  a  time — weeks  or  months — 
that  when  it  is  planted  in  new  ground,  i.e.,  when  another  indi- 
vidual is  infect(Ml,  the  microorganism  recovers  its  former  vitality, 
and  that  when  reintroduccnl  into  the  original  host  all  the  symp- 
toms and  signs  of  an  acute  attack  of  gonorrhea  are  manifested. 
For  example,  a  man  has  acute  gonorrhea  which  ends  in  a  chronic 
gleet.  He  infects  his  wife  and  later  is  reinfected  by  her  and  has 
another  acute  attack  of  gonorrhea.  In  the  course  of  time  each 
becomes  tolerant  of  the  gonococci  of  the  other.  The  husband  has 
intercourse  with  a  prostitute,  suffers  a  fresh  attack  and  reinfects 
his  wife.  This  explains  why  the  gonococcus,  even  after  years  of 
apparent  cure,  may  regain  its  full  virulence.  Such  authorities  as 
Wassermann  {Berl.  Klin,  Woch.,  1897,  No.  32,  p.  685),  Maslovski, 
DeChristmas,  and  JuUic^n  agree  that  there  is  no  immunity  in  gon- 
orrhea, one  attack  giving  no  exemption  from  the  disease  in  the 
future.  It  argues  for  n^jjc^ated  examinations  of  a  gleety  urethral 
discharge  in  the  male  before  advising  marriage. 


are  IIk'  rhit'f  lurking  |jla*'i'.s  for  the  gnne^cuceiis  in  tlio  fcnmlc  gi^nital 
apparatus. 

Differential  Diagnosis  of  Chronic  Gonorrheal  Endometritis* — 
Clironic  gonorrheal  (^ntiunirtritb  mtiy  Ix*  uilstaki^Ji  fop  the  j^iniplo 
fonns  of  endometritis.  A  gonon*heal  «>rigin  of  an  entiometritis 
may  t>e  sn^pectcnl  from  the  history  of  tlie  case;— an  aeuto  attack 
witli  purulent  dbcharge  and  painful  rnieturitkm  folknving  a  sus- 
j>ieioiis  intercoui-si*.  Occasionally  there  is  a  history  of  the  patient 
having  ha4:l  a  bulx)  or  gonorrheal  inHaniniation  of  the  joints.  More 
conunonly  no  such  history  is  ol>taiiialile.  It  is  seldom  advisidjle 
to  in>rtitutc  too  nnnute  inquiries  in  this  direction  in  the  ea^e  of 
nmrriefl  women  Ix'cause  of  the  risk  of  causing  trouble  between 
huslmn<l  and  wife, — trouble  which  can  not  Ix*  cunnj  by  the  physician, 

Tulml  disease  is  found  in  conjunction  with  all  forms  of  endome- 
tritis, but  more  eomni*mly  with  the  se|itic  and  gonorrheal  forms. 

In  mo8t  cas<^8  rejx'ated  Imeteriological  examinations  of  t!ie  dis- 
cliarge  from  the  cervix  are  the  only  way  of  distinguisliing  to  a 
certainty  the  cause  of  the  inflammatory  |nx>ce8s.  The  results  of  the 
examinations  are  so  often  negative  that  we  Eiv  left  with  only  a 
probable  diagnosis  founded  on  the  history  alone. 


Senile  Emjomhtritts 


Senile  enrlometritis  is  an  atrophic  form  of  endometritis  occurring 
in  women  who  have  passed  the  menopaiLse,  oecurrhig  particularly 
in  |XK>rly  nouiished  subjects.  It  is  due  to  the  infection  of  the 
atrophying  nmeasa,  but  what  causes  the  infection  is  not  known. 
Pathologically  the  (endometrium  is  found  thinned,  the  glandular 
elements  are  wanting,  and  many  times  the  endometrium  is  entirely 
replacted  by  connective  tissue.  Them  may  be  stenosis  of  the 
uterine  cavity  from  adhesion  of  the  walls,  and,  from  the  same  cause, 
the  retained  secretions  may  form  a  senile  |>yometm  or  liytlrometra. 
The  latter  is  very  rare.  The  symptoms  have  an  insidious  onset,  a 
thin,  purulent,  often  offensive  and  irritatm^  vaginal  discharge 
binng  the*  chief  symptom.  Pruritus  vulvie  is  common,  also  vulvitis. 
Sonietinjes  the  diseliarge  is  tinged  with  bloiHl  There  may  lx» 
jsrymptomj*  of  mild  sepsis  if  the  discharges  are  retained,  and  in  thia 
pelvic  pains  are  to  Ix^  exjx»eted* 


184  THE  DIAOXaSLS  OF  ENDOMETRITIS 

The  physical  signs  show  the  uterus  to  1k»  small  (unless  there  is 
pyometra),  and  the  cervix  uteri  is  atrophied.  An  attempt  to  pass 
the  sound  will  reveal  partial  or  complete  atresia  of  the  uterine  canal. 
If  the  canal  is  patent  the  discharge  is  seen  issuing  from  the  os.  The 
disease,  coming  as  it  does  after  the  menopause  and  attended  as  it  is 
by  a  foul  discharge,  may  be  mistaken  for  carcinoma  of  the  cervical 
canal  or  body  of  the  uterus.  Dilatation  and  curetting,  with  an 
examination  of  the  tissue  removed,  will  settle  a  doubt. 

ENDOCERVicrris 

Endocervicitis  is  a  chronic  inflammation  of  the  mucosa  of  the 
cervical  canal.  It  is  called  also  cervical  catarrh  and  cervical 
endometritis.  The  disease  is  confined  to  the  cervix  uteri, — there 
is  no  extension  to  the  mucosa  of  the  corpus  uteri.  This  is  a  common 
affection.  The  gonorrheal  form  has  been  described  under  chronic 
gonorrheal  endometritis.  Lacerations  of  the  cervix  are  a  frequent 
cause.  When  the  cervix  is  torn  the  lips  become  everted  and  are 
subjected  to  trauma  from  (1)  pressure  on  the  posterior  wall  of  the 
vagina  by  scybalous  masses  in  the  rectum  resting  on  the  unyielding 
sacrum,  or  (2)  from  excessive  coitus.  x4nother  conmion  cause  of 
endocervicitis  are  polypi  originating  either  in  the  mucosa  of  the 
cervix  or  corpus. 

The  cervical  tissuc^s  in  endometritis  become  hypertrophied,  the 
mucosa  is  eroded,  and  cystic  degeneration  develops.  Infection  is 
difficult  to  dislodge  as  the  bacteria  occupy  the  glandular  crypts. 

Erosions  of  thk  Cervix  Uteri 

Characteristics. — Erosions  of  the  cervix  uteri  are  characterized 
by  a  dark  red  or  purplish  color  of  the  tissues  immediately  around 
the  extenial  os  uteri.  Having  the  appearance  of  ulceration  they 
were  formerly  believed  to  be  true  ulcers. 

In  an  erosion  there  is  no  inflammatory  action  accompanied  by 
destruction  of  the  epithelium  as  in  ulceration.  The  surface 
squamous  epithelium,  which  normally  covers  the  cervix,  is  re- 
moved,— it  is  eroded, — and  the  underlying  colunmar  epithelium  is 
hypertrophi(Hl. 

(1)  A  simple  erosion  pr(\sents  a  uniformly  smooth,  velvety  surface 


EROSIONS  OF  THE  CT.RVIX  I  TERT 


isr> 


with  *Hlmrply  dcfhitHl  rd^t's,  Un  luirnjscopic  rxaiiiination  it  is 
seen  to  consist  of  a  .single  layer  of  coluiuiiar  epitheliuai  witli  little 
or  no  fornmtion  of  new  glantls, 

(2)  ^4  papillamj  ei^omon  lias  an  irregular  projeetion  of  its  livi'l 
red  surface  and  !ia.s  been  cailed  **coek\s-corab  granulatione."  Here 
the  microscope  shows  deep  invaginations  of  the  columnar  epithe- 
lium to  fonu  glandrtj  alternating  with  elcA^ations  made  up  of  newly 
formed  connective  tishue  anil  rounii  eells.  The  glands  secrete  a 
vi.seid  mucus. 

(3)  A  follicular  erosion  is  one  in  wliieh  retention  cysts— the  so- 


Fio.  ^. — Eroflion  of  the  Cervix  with  Liice rations. 
(H.  Macuaughtoa-Jones.) 

called  Nabothian  follicles — are  present  in  considerable  number. 
These  eyst8  are  fornM^l  hy  the  occlusion  of  tfie  newly  formed  glands 
n-ferrtH]  to  in  the  destTi[>tinri  of  the  papillary  rnision.  They  are 
fillc<l  with  inspijssated  mucus  and  vary  in  numbcT.  There  may  Ix^ 
liidf  a  dozen,  or  the  cer\ix  may  he  fairly  riddled  with  them.  In 
dxe  they  var}'  from  a  BJi  shot  to  an  English  walnut  in  extreme 
0218^*8.  They  are  usually  nnt  larger  than  a  p<m.  To  the  examining 
finger  the  retention  c\'i?t  feels  like  a  shot;  to  the  eye  it  api)ears  as 
a  little  mundeil  elevation  of  a  bluish-white  or  yellow  color 

Diagnosis. — Leucorrhea  is  the  constant  spiiptom  of  entlocervi- 
citii*-  The  diagnosis  is  made  by  digital  and  speculum  examinations. 
The  finger  detects  lacerations,  the  soft  velvety  surface  of  the 


186  THE  DIAGNOSIS  OF  ENDOMETRITIS 

erosion,  the  stringy  plug  of  mucus  in  the  as,  shot-like  retention 
cysts,  and  tenderness  of  the  tissues  of  the  cerv^ix.  The  speculum 
shows  the  scars  of  the  lacerations  and  thus  their  extent,  the  dull 
red  roughened  surface  of  the  erosion,  the  plug  of  nmcus  in  the  as, 
l)olypi,  and  retention  cysts,  if  they  exist.  The  fact  that  erosions 
are  found  in  the  virgin  and  even  in  the  infant  (see  Chapter  XXVIII., 
page  563)  must  be  borne  in  mind.  The  determining  factor  in 
the  causation  of  this  condition  seisms  to  be  the  exposure  of  the 
columnar  epithelium  with  which  the  canal  of  the  cervix  is  lined 
to  the  conditions  which  obtain  in  the  vagina  where  the  mucous 
membrane  is  paved  with  squamous  epithelium. 

Differential  Diagnosis. — The  differential  diagnosis  concerns  itst^lf 
with  the  exclusion  of  ulceration  due  to  (1)  an  ill-fittuig  pessary, 
(2)  to  tuberculosis;  (3)  to  chancre  or  chancroid,  and  (4)  to 
carcinoma.  All  forms  of  true  ulceration  are  rare, — erosions  ai-e 
common. 

(1)  Ulceration  from  an  Ill-fitting  Pessary, — If  an  ill-fitting  jx^ssaiy 
has  l)Lvn  removed  and  the  ulceration  does  not  promptly  h(»al  under 
approjmate  treatment  a  piece  of  tissue  should  be  excised  under 
cocaine  anesthesia  and  examined  microscopically. 

(2)  Tuberculoids  Ulcer, — Evidences  of  tuberculosis  elsewhere  in 
the  body,  a  history  of  tulx^rulosis,  and  microscopic  examination 
of  the  discharge  and  a  piece  of  excised  tissue,  will  establish  the 
diagnosis. 

(3)  (a)  Cliancrc. — The  history  is  an  important  consideration. 
A  definite  period  of  incubation  of  th(»  disease  is  present  an<l  the 
symi)tomat()l()gy  and  signs  are  those  of  syphilis.  Chancre  is 
s(»ldom  i>{'cn  in  the  initial  stage,  i.e.,  Ix^fore  ulceration.  When 
ulcerated  it  is  a  single  ulcer.  The  ulcer  heals  under  antisyphilitic 
treatment.  The  differentiation  of  the  Spirocha^ta  pallida  in  a 
piece  of  tissue  removed  for  microscopic  examination  makes  the 
diagnosis  certain. 

(h)  Chancroid. — Here  one  finds  multiple  ulcers  appearing  soon 
aftc^r  a  suspicious  intcTcourse  and  no  symptoms  of  syphilis. 

(4)  Carcinomatous  Ulcerations. — Th(\se  are  generally  attendetl 
by  much  thickc^ning  of  the  surrounding  tissues  and  bletnling. 
A  piecc^  of  tissue  should  be  excised  and  sent  to  the  pathologist  for 
microscopic  examniation. 


niAFFKR    XII 

THK   DlAliNOSlS   OF   PELVIC    INFLAMMATION 
(Pehnc  Peritonitis  and  Pelvi4:  Cell  ul  it  in) 


187 


Routes  of 


Dcfi  nil  ions,   pelvic   j>eritoniiis  and   pelvic   celhilitii*,   p. 
infeetion  in  jn^h  io  inilfimmatioii,  p.  187. 

Pelvic  j>eritoiiiliH,  p.  188:  Analomy,  p.  188.  Ktiology,  p.  1HJ>.  Viirletiis, 
p.  IfM);  Acute  f>elvic  fierih>nitis,  p.  IflO.  Chronic  fielvie  peritonitis,  [>.  11)1: 
Tiiljercnlous  pcrJtaniti.H,  p.  IIH. 

Peh-ic  n'llulitis,  p.  \\H:  Anatomy,  p.  UH.  litiology  ami  piitliolcigy,  ]>.  Ul'i; 
Pelvic  ahstx-ss.  p.  lM:i.    Sympltuns,  ji.  U):?.     Dia^iosis,  p.  104. 

Tabic  of  flitferentinl  cliagiiosiH  of  j>elvic  rnflantination,  p.  1!1*k 

Definition. — The  tonii  prlvir  inflanmiation  rfgnifies  broadly 
inHaniniatory  at'tion  situated  in  any  of  the  ^nicturos  occupying 
tlu*  |K*Ivds.  It  will  !>('  usnl  in  this  rhai)trr  tn  nican  inflaniniatinn 
in  the  [Jtrntoneuiu  which  eovei's  tlu*  pidvic  orgau,'^,  and  in  the  under- 
Ijing  cellular  connective  ti.HHue  of  the  p*^m. 

The  inflannnatnry  prDcess  wlieti  eonfinrd  to  the  pf^lvie  peritoiieum 
con.stituti'S  a  jx*Ivie  jjiTitonilis,  and  when  in  the  ja^lvie  cellular 
tM8ue  a  pelvic  cellulitis. 

Peine  PeritmiitiH, — This  is  a  ver>^  common  affection  and  acconi- 

.pduiici^  in flainniatory  affections  of  the  ovaries  and  tulx^s,  as  well  as 

.inflainmattoii  of  the  jwritunrum  of  the  cntin'  pf^i'itonral  (*avity. 

The  inflammation  extends  to  i\w  ceilular  tissue  from  propintiuity 

and  theit'fore  the  two  processes  are  often  coniltineth 

Pelvic  Cellidiiis, — This,  on  the  other  han<l,  is  a  rare  affliction 
following  lalx)r  or  alKJrtion  and  exhihits  less  tendency  to  extend  to 
the  peritoneum  and  to  the  overlying  structures.  It  is  often  ini* 
I>otvsil>|i^  to  different iat<'  Mween  the  two  varirtii*s  cjf  p<*Ivir  iriflain- 
matjon,  esjx'eially  in  the  Iat<*r  stages.  An  attempt  will  Ix*  made 
to  dcHcrilx*  lK>th  forms,  Ix-ginning  with  the  more  iniijortant:  first, 
flaying  scmK thing  of  the  routes  of  infection  and  the  character  of 
the  structures  involved. 

Routes  of  Infection  in  Pelvic  Inflammation.  —In feetion  may  rearh 
the  pc*Mc  peritoneum  and  cellular  ti.ssui*  (1)  from  tfsf*  tjutsidr, 
tlirotigh  \}w  hinu^n  of  the  vagina,  uterus,  ami  tubc?s,  or  (2)  from  the 
L1<hh1  rurniit  and  tl»e  lymphatics. 

187 


188  THE  DIAGNaSLS  OF  PELVIC  INFLAMMATION 

1.  It  is  possible  for  infection  to  travel  through  the  vagina,  uterus, 
and  tubes  without  leaving  traces  Ix^hind  it.  Often,  at  the  time  the 
patient  first  conies  under  obsei-vation,  the  inflammatory  processes 
in  these  structures  have  bumcKl  themselves  out. 

2.  The  blood  or  lymph  vessels  may  bring  infection  to  the  pelvis 
from  distant  organs,  though  this  is  rare.  Generally  the  infective 
microorganism  is  near  at  hand  either  in  the  uterus,  tubes,  bladder, 
or  rectum,  rarely  in  an  infected  ovarian  cyst,  a  suppurating  appen- 
dix vcrmiformis,  or  the  large  or  the  small  intestine. 

Occasionally  infection  comes  to  the  pelvis  in  a  psoas  abscess  or 
other  abscess  of  distant  origin,  such  as  an  abscess  about  the  sacro- 
iliac or  hip  joints.  The  following  bacteria  have  been  found  in 
cases  of  j>elvic  inflammation,  generally  in  mixed  culture,  and  they 
may  be  classed  as  causative  of  the  inflammation: — 

Gonococcus. 

Colon  bacillus. 

Streptococcus  pyogenes. 

Stai)hylococcus  pyogenes  albus,  aureus,  and  citreus. 

Tubercle  bacillus. 

Diphtheria  bacillus. 

Typhoid  bacillus. 

Pneumococcus. 

Actinomyces. 

PELVIC   PERITONITIS 

Anatomy 

The  pelvic  peritoneum  covers  the  concave  surface  of  the  floor 
of  the  pelvis.  Beginning  on  the  anterior  wall  of  the  abdomen 
behind  the  pubes  and  passing  dowTiward  and  backward,  it  covers 
first  the  post(Tior  surface  of  the  bladder.  In  this  situation  it  is 
loosely  adh(4-ent  and  has  more  or  less  cellular  tissue  under  it. 
From  the  bladder  it  reaches  the  uterus  just  below  the  level  of  the 
internal  os  and  tiienct*  rises  over  the  anterior  aspect  of  the  body  of 
the  uterus.  This  low(\st  i)ortion  forms  the  so-called  vesico-uterine 
pouch.  Passing  ov(»r  the  fundus  of  the  uterus,  where  it  is  closely 
adherent,  the  peritoneum  is  continued  on  the  posterior  surface 
of  the  body  of  the  uterus  to  a  point  a  little  below  the  level  of  the 
internal  os  where  it  leaves  the  uterus  to  dip  down  deep  in  the  pelvis 


PELV IC  PER  ITOXIT LS 


189 


to  tonn  the  cul-fle-sac  nf  Douglas.  It.s  k»wo8t  fioint  in  ihv  ouI-dc*-8uc 
varies,  but  averages  half  an  inch  or  so  Ix^low  the  attachment  of  the 
vagina  to  the  cervix.  Rising  from  thr*  nil-dt'-sae  of  Douglas,  the 
^peritoneum  roaches  first  ttip  anterior  [»art  of  tlic  middle  portion  of 
the  rectum.  Higher  uj)  it  reaches  the  m\vf^  of  this  vigscu^s  and  still 
higher  the  posterior  portion  of  the  first  part  of  the  rectum.     At 


L 


/,: 


Fio.  70. — Reflection*  of  the  Folds  of  the  Peritoneum 
(UotltHl  Lines). 

sides  of  the  uterus  the  folds  of  the  peritoneum  fomi  the  broad 
aeut^s.    Aljove  they  vayvv  the  Fallopian  tubes  and  the  posterior 
of  the  ovaries. 

Etiology 

Pelvic  peritonitis,  the  more  common  of  the  two  sorts  of  pi^vic 
tnflamfnation,  is  almost  always  secondary  to  salpingitis.  It  may 
follow  the  escape  of  pus  or  even  menstrual  blotxl  or  injected  fluid 
the  ostiimi  abdominale  of  the  Fallopian  tube*,  or  it  may  follow 
tic  metritis,  cystitis,  [»roc»titi.s,  jH^rforntion  of  thr*  uteruB,  appendi- 
citis, or  pmoF  alif^ess. 

The  ^onococcus  and  strtptococcus  are,  lis  far  as  we  know,  the 
bacteria  mosft  frecjuently  tlie  cause  of  pelvic  i>eritonitis. 


190  THE  DIAGNOSIS  OF  PELVIC  INFLAMMATION 

Varieties 

The  disease  is  acute  or  ehronie. 

Acute  Pelvic  Peritonitis. — ^This  is  manifest<^d  by  slmrp  pains  in 
the  lower  abdomen  and  pelvis,  rigidity  of  the  abdominal  nmscles, 
tenderness  to  examination  both  of  the  alxlomen  and  the  vagina, 
fever,  rapid  pulse,  nausea,  vomiting,  constipation,  and  nervous 
depression. 

The  greater  the  tendency  of  the  peritonitis  to  become  a  general 
peritonitis,  the  more  pronounced  are  the  symptoms.  If  the  resist- 
ing power  of  the  individual  is  great,  i.e.,  a  high  opsonin  index  is 
present,  and  the  virulence  of  the  inf(»cting  bacteria  little,  or  the 
dose  small,  the  inflammation  may  sulxside,  leaving  behind  it  ad- 
hesions between  the  opposing  folds  of  pcTitoneum.  Thus  the  tub(*s 
become  glued  in  the  cul-dc^sac  frecjuently,  and  coils  of  intestine? 
are  fast(»ned  to  the  tutes.  In  the  sc^venT  grades  of  inflammation 
the  omentimi  helps  to  wall  off  the  process  from  the  general  cavity 
of  the  peritoneum.  It  appHes  itself  to  an  inflamed  tube  in  an 
ahnost  intelHgent  manncT.  If  r(\solution  does  not  occur  because 
of  the  great  virulence  of  the  infective  material  or  lessened  resistance 
of  the  patient,  a  chronic  pelvic  peritonitis,  or  a  pelvic  abscess, 
results.  A\'ithout  treatment  such  a  pelvic  abscess  most  commonly 
opens  into  the  rcK'tum,  although  it  may  find  exit  into  the  bladder  or 
through  the  abdominal  wall.  It  very  rarely  opens  into  the  uterus 
or  vagina. 

The  diagnosis  is  estabHslird  by  the  presence  of  the  symptoms 
above  noted  and  by  the  pliysical  signs,  which  are: — on'  bimanual 
examination  the  vagina  is  hot,  dc^noting  increased  body  tempera- 
ture; the  uterus  is  fixed  and  there  is  a  sense  of  resistance  in  the 
tissues  occui)ying  tho  pelvis,  a  board-like  f(*eling.  This  induration 
of  the  i)elvic  tissues,  eouphnl  with  the  rigidity  of  the  abdominal 
walls  and  great  tendern(\^s  to  light  pn^ssure,  make  it  impossible  to 
map  out  th(!  contents  of  thc^  i)elvis  with  exactness.  Atumormas.s, 
if  pres(*nt,  is  high  up  in  the  pelvis.  The  uterus  may  or  may  not  be 
misplaced  according  to  the  situation  of  the  greatest  amount  of 
(^xudate.  If  then^  is  an  al)sc(\'<s  pr(\*^ent  a  point  of  softening  is  to 
be  s(^arched  for.  Abscess,  h()W(»v(M*,  is  generally  rare  and,  if  present, 
occurs  in  the  later  stages  of  pelvic  pcM'itonitis.  Speculum  examina- 
tion aids  little  in  the  diagnosis  of  this  affection.     The  uterine 


CHRONIC  PELVIC  PERITONITIS 


101 


lisctiarges  an?  climinLshptl  at  the  on.^t  antl  increased  in  the  lattT 
^es.  The  detection  of  a  vagiaitis  may  show  tlie  origin  of  a  pelvic 
IM'ritoiiitis  and  the  isnlntitm  of  an  infective  bacterium  nifiv  .sliow  its 
nature.  So  also,  examination  of  the  rectinii  or  l>laddcr,  should 
symptoms  point  the  way,  may  help  us  to  find  the  route  taken  by 
the  inftrting  agent  in  reaching  the  pel%ic  peritoneum.  Examina- 
tion of  tlie  blood  generally  f^hows  an  increase  in  tlie  numlver  of  white 
cells,  ahhough  this  is  not  an  invariable  concomitant. 

Chronic  Pelvic  Peritonitis, — This  begins  witli  an  acute  attack, 
althctugh  the  syni^itoms  may  Ix*  of  inconsiderable  moment,  so  as  to 
j^escsix!  the  patient 3  notice.  Often  thi*re  will  l>e  a  history  of  a 
?ries  of  acute  attacks  separateil  by  interv^als  of  months  or  years. 
[The  symptoms  are  fiain  of  a  dull  char-acter  in  the  pehde  region, 
kache,  constipation  and  {minful  defecation,  rhsturbancc  of 
Ider  function,  and  pfjor  health.  l'hysi<'al  examination  reveals 
larger  or  smaller  amount  of  exudate  and  limitations  of  the 
[liioliility  of  the  utrrus,  tulx^s,  and  ovaries  due  to  adliesious.  Th(\sc 
[organs  are  apt  to  fx*  displac^ed  a.s  well  as  enlarged.  TendcTnes;^  in 
the  ehn>nie  stage  is  not  a  prominent  factor  as  in  tlie  acute  form. 
Pchic  absce^  may  re^^ult  in  the  coim?e  of  a  chronic  pelvic  pCTi- 
Ltoiiitis.  Tills  will  U^  describni  more  in  detail  under  pelvic  celhilitis, 
;  it  IS  more  often  found  in  the  latter  affection. 
TuheradmiH  Peritonitis, — Tuberculous  |>eritonitis  is  one  variety 
chronic  jH'Ivic  ixTitonitis.  Here  the  disc^as**,  as  seen  clinically, 
Ks  seldom  limitinj  to  the  jx'lvi.s,  Iw^ing  an  affair  of  the  general  peri- 
Itoneum. 

The  disease  t)i*ginf*  in  the  Fallopian  tuV^rss  in  a  vast  majority  of 

instance^*,   and   is  sometimes   seen   and   diiignose<l   be-fore   it   has 

Fi-iiehe*!  the  general  peritoneal  cavity.     It   is  characterized  by  a 

^railuai  onset,  by  fever  recurring  every  evenirig  and  disappearing 

in  the  monijng,  rapid  i>ulsi%  sweathtg,  particularly  at  night,  loss 

of  weight,  lo^s  of  strength^  and  anorexia.     As  the  ilisease  progresses 

'there  b*  enlargement  of  tlie  alxlonien  ilue  to  the  prei^ence  of  plastic 

exuilate  or   to    the  accumulation  of  Huid.     Early  in  thr  disc^asc 

.nothing  characteristic  can  lie  made  out.   An  enlargement  of  a  tube, 

^mith  .surrounding  exudate,  increasing  hi  size  w^hen  examined  at 

repeftttHJ  intervalf^i  roni>letl  with  a  family  history  of  tul)erculosis, 

previous  tuberculosis  in  some  other  organ,  and  the  symptoms  just 

eoutuemtetl,  make  a  prol>al)Ie  iliagnosis  «^tf  tulx^r(^ulous  pehic  fjer- 


192  THE  DIAGNOSIS  OF  PELVIC  INFLABIMATION 

itonitis.  Elimination  of  the  other  causes  of  salpingitis,  such  as 
gonorrhea,  may  be  of  assistance.  The  disease  is  found  most  often 
in  virgins.  In  chronic  pelvic  peritonitis  we  do  not  expect  to  find 
leucocytosis,  even  if  an  abscess  is  present,  although  it  may  occur. 
Pelvic  peritonitis  leaves  behind  it  many  disabling  lesions  in  the 
shape  of  adhesions  and  displacements.  It  is  the  cause  of  a  large 
l)ortion  of  the  diseases  peculiar  to  women,  and  therefore  should 
receive  most  careful  attention  at  the  hands  of  the  physician. 


PELVIC  CELLULITIS 

Anatomy 

The  cellular  tissue  of  the  pelvis  lies  under  the  peritoneum.  In 
it  pass  the  blood-vessels,  arteries  and  many  large  veins,  and 
the  lymphatics.  It  is  most  abundant  in  the  bases  of  the  broad 
ligaments  and  between  the  peritoneum  of  Douglas'  pouch  and  the 
vagina  and  lower  rectum.  Therefore,  these  are  the  situations 
where  the  collulitis  occurs  most  often.  The  peritoneum  is  pretty 
closely  attached  to  the  uterus,  Fallopian  tubes,  and  ovaries.  That 
is  to  say,  veiy  little  cellular  connective  tissue  is  present  under  the 
peritoneum  in  these  regions.  It  is  less  closely  attached  to  the 
bladder. 

Etiology  and  Pathology 

Pelvic  cellulitis  is  a  relatively  rare  affection.  In  more  than 
two-thirds  of  the  cases  it  is  of  puerperal  origin,  and  is  generally 
due  to  infection  by  the  common  pus-producing  cocci  which  enter 
the  pelvic  celhilar  tissue  from  the  uterus.  Infection  may  come 
from  the  vagina,  rectum,  or  bladder,  or  from  unclean  instrumenta- 
tion or  septic  manipulation.  The  trauma  incident  to  parturition 
opens  the  way  for  the  entrance  of  bacteria.  The  common  situa- 
tions of  the  inflammation  have  been  foreshadowed  in  the  descrip- 
tion of  the  situations  in  the  pelvis  where  cellular  tissue  is  most 
abundant.  The  lymph  vessels  and  veins  are  affected  first.  A 
lymphangitis  or  a  phlebitis  may  be  limited  by  the  plugging  of  a 
vessel  by  a  thrombus,  and  in  such  a  cas(»  infection  goes  no  farther. 

In  pelvic  c(^lluHtis  the  infective  process  extends  to  the  tissue 
about  the  vessels,  the  cellular  tissue,  and  we  have  a  cellulitis. 


PELVIC  CELLULITIS 


193 


Tin*  infc^ctive  inflaiiiniul  i<)ri  may  go  through  all  thrc^e  of  the  niitial 
Htagps  of  inflammation,  i.e.,  eongestinii,  effusion,  and  supimnition, 
or  only  the  first,  or  the  fii*st  two.  Th(^  pniress^  from  a  patliolo*rieaI 
fK^int  of  view,  is  not  iso  different  from  that  of  a  funmck%  namely, 
infect  ion  conveyeil  into  a  eonneetive-tiHsue  area. 

Pelvic  Abscess.— If  the  procet^s  goes  on  to  suppuration  the  pus 
U  evaeuate*!  in  timt*  spontaneously  into  th</  vagina  or  other  pelvic 
viscera,  often  doing  a  g(M)d  deal  of  ilaniiigc*  before  this  issue  is 
attaincHi.  Should  the  ab«ce.S8  opru  intn  the  liladder  or  reet\ini, 
it  h  unlikely  to  heal  and  the  patic^nt  l>(*roni(\s  st»|)tie  and  tlies  from 
Hc^ptieemia  after  a  long  illness.  Tins  is  fretjuentiy  tlie  result  even 
if  most  thorough  tlrainage  is  made,  ])ro\nded  intervention  has 
b(*en  j>08tpon(Hl  until  the  ai)sees.s  has  burrowed  extensively  into 
the  tissues  of  the  pelvis  and  the  resisting  ]>owers  of  the  i)atient 
have  IxM'n  rf*<luenl  to  low  limits.  Early  surgi<"al  interv^ention 
and  drainage  of  the  abscess  into  the  vagina  result  in  s[HH*<ly  Inal- 
ing,  just  as  in  the  case  of  a  boil,  with  notliing  h'ft  behind  cx^-fpt 
iualix>sition  of  the  utenis,  tulx's,  nm\  ovaries,  and  rarely  ilishication 
of  the  blatlder,  or  strif*ture  of  the  rectum  or  urethra. 

There  is  no  tendeney  to  reeurn^nee  and  nn  ehn^nie  process  as 
in  the  cas<?  of  p<*lvic  peritonitis,  wliere  thc^  itiHamnuition  originates 
ill  the  Fallopian  tul>e,  whiclj  is  !irit*d  with  mucous  mt^mbrane. 
It  is  a  welt-known  fact  that  infection  tendi?  to  lurk  in  mucouH 
membranes,  and  it  does  not  rem?dn  in  the  cellular  tissue.  Forms 
of  chronic  cellulitis  have  Ix^en  d(^serilxHI,  such  as  t lie  chronic  atrophic 
e4^llulitis  of  FrfHUid,  alsc^  an  edematous  form.  It  is  a  <tiif'^tion,  how- 
ever, whether  such  processes  really  originate  in  the  (*(*llular  tissue. 

A  i^wlvir  aljsi'ess  may  n'sult  from  a  ru]>tun*  of  a  pyosaliiinx  into 
the  cellular  tissue  of  the  broad  ligainc^it  or  <>f  th(^  retrouterine 
s|)aee.  In  this  ca^  one  would  expt^et  that  tin  hruling  process 
would  he  more  protractetl,  and  such  is  generally  the  case.  So  also 
in  ^vere  gi-ades  of  cpllulitis  originating  in  the  uttTUs,  the  over- 
Ijing  tubes  and  ovaries  Ix^conu*  infecttnl  by  extension  and  have 
to  be  reckontil  with  in  the  treatment  and  prognosis. 


Tlie  symptoms  of  pelvic  cellulitis  are  (a)  general,  those  common  to 
tion»,t.c,,  fever,  rapid  pulse,  chills,  prostration;  and  (6)  local, 

13 


194  THE  DIAGNOSIS  OF  PELVIC  INFLABfMATION 

severe  pain  in  the  pehis,  sensitiveness  to  light  touch,  both  of  the 
abdomen  and  the  vagina,  also  dysuria  and  painful  defecation.  The 
local  symptoms  abate  quickly,  even  if  the  process  goes  on  to  sup- 
puration, and  most  rapidly  if  resolution  occurs. 

Diagnosis 

By  conjoined  manipulation  there  is  found  a  tumor  in  the  pehis 
occupying  the  region  of  the  broad  ligament  on  one  side,  or  the 
retro-uterine  space  behind.  The  recto-abdominal  touch  is  espe- 
cially useful  in  diagnosing  this  affection.  If  the  mass  is  in  the 
usual  situation  in  the  base  of  the  broad  ligament,  the  uterus  is 
crowded  to  the  opposite  side,  the  tumor,  wliich  is  hard  or  boggy 
to  the  feel,  bulgi^s  into  the  vagina.  If  the  tumor  is  in  the  retro- 
uterin(»  space  the  lumen  of  the  vagina  is  encroached  upon  and  the 
bladder  and  cervix  are  crowcUnl  forward  against  the  pubes  and 
anterior  alxlominal  wall.  In  the  acute  stage  there  is  rigidity  of  the 
abdominal  muscles,  as  well  as  sensitiveness,  so-called  peritonismus. 
This  soon  subsides.  In  th(^  later  stages  when  there  is  abscess  for- 
mation it  is  difficult  to  find  the  situation  of  the  uterus  without 
the  aid  of  a  sound.  There  is  a  mass  in  the  pehas  that  may  occupy 
nearly  the  (^ntire  cavity.  The  pus  generally  burrows  into  the 
n^tro-utoriiK^  space.  Rc^ctal  examination  will  often  show  the 
upper  limits  of  the  tumor;  combined  rectal  and  vaginal  examina- 
tion is  always  of  value  in  mai)ping  out  the  size  and  form  of  the 
soi-t  of  cc^llulitis  that  Ix^gins  in  the  rt^tro-uterine  cellular  space. 
In  sonu*  cases  there  is  markcMl  iMleniatous  thickening  in  the  space 
Ix^tween  the  u\)\)vv  and  middh^  portions  of  the  vagina  and  the 
rectum.  This  is  i)ali)at(^d  with  great  exactness  by  one  finger  in 
the  rectum  and  anotlier  in  the  vagina.  The  detection  of  fluctua- 
tion in  a  pelvic  abscess  in  not  easy  bi^ause  thick  walls  of  lymph 
arc*  effus(Ml  and  encompass  a  collection  of  pus  of  any  considerable 
size. 

Often  an  effusion  of  blood  in  the  jxTitoneal  ca\ity,  a  pehic 
hematocele  of  sevi^ral  weeks'  standing,  simulates  a  pelvic  abscess. 
The  hematocele  sluuild  have  a  boggy  feeling,  not  unHke  feces  of 
pasty  consistency,  but  on  ac(H>unt  of  the  wall  of  organized  hinph 
with  which  it  is  surroundcxl  and  the  tension  of  the  contents  of  the 
sac  there  may  Ix'  no  boggy  feeling.    The  history  of  the  begmning 


DIFFERENTIAL  DUONaSiS  OF  PELVir  INFLAMldATION      195 

of  the  attark^  if  obtainable,  will  throw  light  on  the  diagnosis, 
hematocele  Ixiiig  ushered  in  by  severe  pain  and  rectal  tenenmus, 
and  with  prostration  but  no  fever.  Pelvic  cellulitis  always  begins 
mih  fe\Tr. 

The  sequelae  of  pelvic  cellulitis  siw  not  so  serious  as  those  of 
{)ehnc  peritonitis.  Neglectcil  cases  may  leave  crippling  trace^i 
beiausc  of  the  involvement  of  ovaries?,  tubes,  rectum,  ureter,  or 
bladder.  Cas4\s  which  end  in  sfM»e<Iy  n^snlution,  eitlier  sijon- 
taneously  or  Ix^aiLse  of  prompt  surgical  interference,  often  leave 
no  other  traces  than  a  cicatrix,  or  a  small  area  of  induration  in 
the  vagina. 


DIFFERENTIAL  DIAGNOSIS  OF  PELVIC  INFLAMMATION 

The  following  table  of  the  diQcrential  diagnosis  of  jx^vic  inflam- 
mation ha*^  Ix^en  modilinl  from  that  in  E,  C\  DutUey's  '*  Text- 
book of  Gynecology  *' : 


Pdme  PcriUmitis. 

A.  ExxuiaUi  surruunds  uterus  and  ta 
wpi  to  hn  high  in  pelvis, 

Fi.  Utcnw  fixwl  wherever  it  happ^iiii 

be, 

C.  Pain  seven!  and  paroxysmal  in 
mrute  staip?, 

Li.  Tendency  to  mippuration  not 
pULfked. 

K-  Frvciueniiy  resuJtA  in  general 
pv»ntonituf> 

F.  Constitutioiuil  •yniptotnji  more 
^tpd.     Apt  to  be  QHUaea  and  vomit* 


Pdtdc  CeUidiHa. 

A.  Tumor   usually   at    one   side   of 
uteruA  and  low  in  pelvis. 

B.  t'teru«   displaced    laterally,    not 
neoeswarily  fixed, 

C.  Pain  leas  severe  and  more  con- 
tin  uoals. 

D.  Tendency  to  suppuration  marked. 

E.  Seldom    results   in   general   per- 
i  torn  tin, 

F.  Ckjiistitutfonal      sjTnptoms     less 
severe.     No  nausea  and  vomiting. 


P^vic  PeriUmitu  in  Dmt(tUu'  Cul^ie-mc 

Tumor  mtiAs  han  a  »\u\r\y  outline 
m  n'latively  liiich  in  |iel\i^, 

B.  Uterus  is  disiilaeed  fon^^ani 


Hftro^uijeHne  CeUidttis, 

A.  Tumor  mass  of  indefinite  outline 
is  situatwl  in  the  apace  between  rectum, 
vagina,  and  uterus  in  pehic  floor  and 
ia  flattene^i  in  form, 

B,  Cer\ix  uteri  alone  bent  for^anl 
or  to  the  aide,  not  the  body  and  fundus. 


196 


THE  DIAGNOSIS  OF  PELVIC  INFLAMMATION 


Pyoaalpinx. 


Pelvic  CeUtUUia. 


A.  Mass  on  one  or  both  sides  of  A.  Mass  on  one  side  of  uterus  only 
uterus  and  back  of  it,  not  bulging  into  and  low  in  the  pelvis,  bulging  into  the 
the  vagina.  vagina. 

B.  Mass  of  shaq?  outline  and  sausage-  B.  A  diffuse  swelling, 
shaped. 

C.  Mass  partly  movable.  C.  Mass  fixed. 


Chronic  Pelvic  Hematocele. 

A.  History  of  tubal  pregnancy  with 
symptoms  of  sudden  internal  hemor- 
rhage.    May  be  rej)eated  light  attacks. 

B.  No  chill  or  fever. 

C.  Relatively  rapid  inci-ease  in  size 
of  tumor. 

D.  Tumor  doughy  and  elastic. 

ApperuHciiis  with  Abscess. 

A.  Onset  with  severe  symptoms  and 
nausea  and  vomiting. 

B.  Tenderness  over  appendix  region. 

C.  Exudate  high  up  in  pelvis. 
Reached  by  vaginal  or  rectal  examina- 
tion only  with  difficulty. 


Psoas  Abscess. 

A.  History  and  symptoms  of  tuber- 
culosis. 

B.  Exndences  of  Pott's  disease. 

C.  No  history  of  acute  onset. 

I).  Limitation  of  motion  and  pain  in 
thigh. 

Subserous  Myonm. 

A.  No  history  of  infection. 

B.  No  history  of  acute  onset. 

C.  Contour  of  the  tumor  rounde<l, 
sharply  defined,  and  tumor  intimately 
connected  with  the  uterus. 


Pelvic  CellulUis. 

A.  History  of  infection. 

B.  Chills  and  fever. 

C.  Slow  development  of  tumor. 

D.  Tumor  hard  until  suppuration. 

Peine  CellulUis  {Right  Side). 

A.  Onset  with  less  severe  symptoms; 
no  nausea  and  vomiting. 

B.  No  tenderness  over  appendix 
region. 

C.  Exudate  low  in  pelvis  in  base  of 
broad  ligament  or  in  retro-uterine  space. 
Easily  palpated  through  vagina  an<l 
rectum. 

Pelvic  CellulUis. 

A.  History  of  non-tuberculous  in- 
fection. 

B.  No  evidences  of  Pott's  disease. 

C.  History  of  acute  onset. 

I).  No  limitation  of  motion  or  pain 
in  thigh. 

Pelvic  CellulUis. 

A.  History  of  infection. 

B.  History  of  acute  onset. 

C.  Tumor  of  indefinite  outline  and 
not  so  intimately  connected  with  the 
uterus. 


niAITER  XIII 

THE    niAGNOSlS   OF   CONGENITAL    ANOMALIES   OF  THE 

ITEFU'S,  LACERATION  OF  THE  CERVIX   UTERI,  AND 

DI8EA.SES  OF  THE  UTERINE  LIGAMENTS 

Diagnosis  of  congenital  nnomafie^  of  the  uterus,  p.  lf>7 :  L  Anomaliea  dui' 
lo  arrest  of  develojjiiienl,  [i.  1I*H  :  Absence  of  llie  titcrus,  p.  198;  Kydiinenturv 
utrrus,  (>,  H>8;  Ulerys  hiparlitus,  p.  "iOi);  Itcrits  iJi<]elpliys»  fi.  "siOO;  Ulerus 
bicorriis,  p.  'HM);  rieru!*  «i<.*ptys.  p.  "200;  tlcnis  unicurnis,  p.  '^00:  Dingnosin, 
p.  ^l;  IHHercntial  «iiii^iiosi3.  p.  ^Oi.  IL  Atitvrujilies  due  ti)  arrest  of  grnwlh, 
p,  ^(Hi  Itifarilik*  ulenis,  p.  ^0;i;  ('aiigenitul  atrophy*  p.  *£0:i;  Pueqjeral 
alrnphy,  p.  tO'A:    Non-puerperal  iilropliy,  p.  'iOH, 

Diagnosis  of  laceration  of  the  cervix  uteri,  p.  204:  Atiatotny,  p.  50 >, 
Etiology,  p.  204.  Mechanism  and  pathology,  p.  205.  Results  of  laceration, 
p.  200:  Subinvolution,  p.  *207;  Diagnosis  of  laceration,  p.  208:  Recent 
lacrrations,  p,  208;    Old  lactTations,  p.  20!>,     Ditferciitial  diagnosis,  p.  210. 

Diagnosis  of  the  discast^^  of  the  uterine  hgaments,  p.  21(»:    The  Unmil 

ligaroents,  p.  2t  1  :  Parovarian  cysts,  p,  21 1 ;  Varia>eele  of  the  hroa*I  lif^arnent, 

p.  212.     The  round  ligaments,  yi.  212:   Tumors,  p.  212;    Hvdnx-ele  of  the 

nuiaJ  of  Nuek,  p.  2K?,     Tlie  ulero-sacral  ligaments,  p.  21J.     The  ulero- 

I  (rvartan  Jigaments,  p,  21 L 


Certain  pointi^in  tlie  anatonjy  and  mechanics  of  the  ytt^riK^have 
been  considen^d  in  Chapter  V,,  page  44,  an<l  others  will  Iw 
dpifcribed  in  Chapter  XI\\,  on  the  diagnosis  of  nial|jo:^itions  of  tlu* 
uteru8»  page^  222-224,  Thr  «_»ndon natrium  hixs  U^vn  deserilx-d  in 
Chapter  XL  on  Endonx^tritis,  page  15(1  In  tht^  presinit  chapter  we 
will  take  tip  the  arrt'«t**^  of  dr'velopnient,  laeeratioius  of  the  errvix, 
and  diseases  of  the  uterine  ligaments. 


DIAGNOSIS  OF  CONGENITAL  ANOMALIES  OF  THE  UTERUS 

Tlie  litems,  which  in  the  virgin  measures  thnn-  inches  in  lengtli, 
two  inches  in  breadtli  at  the  fundus,  and  nearly  an  inch  in  thiekneKs, 
b*  develojied  from  the  coalescence  of  the  two  MuUerian  duet,^  in 
^the    embryo.     Thif?  eoaleseenee    takes  place  from  thv  eighth  to 
rthe  twelfth  weeks  of  fetal  life.    ITie  devt^lopment  should  Ik^  com- 
plete, with  the  septum  I>etwei*n  the  two  ducts  al>sorlied  and  the 


Absence  of  the  Utems. — Compkto  abstmec  of  the  uterus,  t\e., 
thorn  cases  in  which  there  i.s  present  not  even  a  knob  of  tissue  at 
the  u|)per  end  of  the  vagina  to  represent  a  uterus,  is  an  affair  only 
of  non-\dable  fetal  monstrosities  or  pseud  o-liermaphroditos. 

Rudimentary  Utems.— Rudimentary  uterus,  on  the  other  hand, 


200  CONGENITAL  ANOMALIES  OF  THE  UTERUS 

the  [)hysiciaii  Ix^cause  of  the  absence  of  menstruation.  The  case 
of  a  niarrieci  woman  reported  by  me, — **  Congenital  Absence  of 
Uterus  and  V^agina ''  (Atner.  Jour,  of  Med.  Sci.y  March,  1897), 
came  under  obsc^rvation  because  of  the  absence  of  a  vagma. 

The  diagnosis  is  made  by  recto-alxlominal  examination  with  the 
patient  under  an  anesthetic, — also  by  examination  with  a  large 
sound  in  the  bladder  and  the  finger  in  the  rectum.  An  absolute 
diagnosis  can  be  made  only  by  an  abdominal  section  or  by  a  post- 
mortem examination. 

Uterus  Bipartitus. — Uterus  bipartitus  consists  of  a  poorly  de- 
veloped cervix  continuous  with  two  rudimentary  united  comua 
which  are  usually  solid  cords,  but  may  be  provided  with  pervious 
canals  as  in  the  figure.  The  ovaries  are  generally  present  in  an 
undeveloped  state.  Here  only  the  lower  part  of  Miiller's  ducts 
have  succeeded  in  coalescing  to  form  a  cervix,  failing  to  unite  in 
their  upper  portions. 

Uterus  Didelphys. — This  is  rare.  It  consists  of  two  separate 
uteri,  each  with  one  horn,  and  two  separate  vagina).  Sometimes 
the  lowcT  extremity  of  one  vagina  is  occluded  at  some  point  above 
the  vulva  and  may  contain  retained  secretions.  (Sec  Congenital 
atresia  of  the  vagina,  Chapter  XX.,  page  357.) 

Uterus  Bicomis. — Uterus  bicornis  is  a  relatively  conmion  condi- 
tion. In  it  Miiller's  ducts  have  miited  to  form  a  cervix  with  two 
canals  and  two  ora,  but  are  unmiited  above,  so  that  there  are  two 
long  comua  representing  a  uterine  body.  Sometimes  the  union 
has  progressed  to  a  i)oint  a  little  higher  up  in  the  cervix  and  we 
have  one*  (wternal  os  and  one  ccTvical  canal  below,  and  two  cer- 
vical canals  alx)V(^,  or  the  condition  known  as  Uterus  bicomis  uni- 
collis.    (See  Fig.  78.) 

Uterus  Septus. — Uterus  septus  is  the  coalescence  of  the  ducts 
to  form  a  uterus  which  appeal's  to  be  normal  externally  but  within, 
its  cavity  is  divided  longitudinally  into  two  cavities  by  a  persist- 
ence of  th(»  septum. 

Uterus  Unicornis. — Uterus  unicornis  results  from  the  develop- 
ment of  only  one  cornu,  the  other  being  entirely  absent  or  rudi- 
mentary. Th(^  corn^sponding  Fallopian  tube  is  generally  absent. 
If  secretions  accumulate  in  the  rudimentary  cornu,  there  being  no 
outlet,  a  distended  sac  will  be  fornKnl;  but  fortunately  this  is  a 
rare  happening.     Pregnancy  may  occur  in  a  rudimentary  horn, 


ANOMALIES  DPE  T(*  ARREST  OF  DEVELOPMENT 


201 


al:^  in  uterus  tliilclpliys,  ninl,  t>f  ^^rnirsc,  in  utmis  st^ptuH.  (See 
Chaptrr  XXIL,  pagi >433.) 

Diagnosis  of  Uterine  Anomalies  Due  to  Arrest  of  Development.^ 

Tlip  (liagnohiri  uf  uterine  anoiiialie.^  tlue  to  arre>t  of  (trvel(j[jnient 
rt^^s  on  the  gjTnptoniHi  in  the  rare  cases  where  aeeurnulation  of 
secretiom*  forms  a  sac  that  presi^s  on  the  Matltler  or  rertuni,  tjr 
causes  cramps;  or  cases  in  which  menstruation  do(^s  not  occur  at 
tlie  normal  age.  As  I'egartis  thr  lattrr  it  sliould  Ix'  renienibered 
that  menstrual  blood  may  How  from  one  half  of  a  uterus  while  it  is 
rolit^cting  in  the  other  half.  Alxirtion  anrl  prt^niature  labor  are 
more  frequent  in  the  case  of  doul>lr  uterus,  and  the  pres<*nce  of  a 
!S(i>tu?n  makes  delivery  difficult  a!id  involutirm  s|(nv*T,    A  decidua 


^^wf  fftfluU^ 


f/   prn^ffftj'*, 


Fio.  7S- — Btoomuie  Uterus,  One  Ext*?nuU  Os,  Two  Uterine  Cavities.    Removed 
from  Single  Woman  3  J  Ycurs  okl,  Jan.  27,  I9(J3,  fur  lic^lx-Ilioua  Dysmenorrhea, 

forms  in  the  empty  half  of  a  septate  pregnant  uterus  or  in  a  rucli- 
jliientary  horn  just  a^  it  fonns  in  the  uterus  in  the  cas<;*  of  tubal 
pregnancy. 

By  examination  the  presi^nce  uf  two  vaccinal  canals  is  a  definite 
indication  of  a  double  uterus.  If  the  vagina  is  single  the  two  ora 
of  a  iliilelphys  titcrus  n»ay  Ix*  palpated  by  the  examining  finder 
anil  may  U*  s<*(  n  through  the  specuhnn.  Two  uterine  horns,  or  a 
iliviiU*<i  fundus,  may  be  fi»lt  by  bimanual  examination  if  the 
conditions  are  exceptionally  favorable,  that  is,  a  thin  and  lax 
aljdortiinal  wall  and  alis</nce  <»f  much  fat.  If  the  uterus  feels 
nonnal  to  the  birnamial  palpation  except  for  the  presence  of  two 
ora  in  the  cervix,  two  sounds  are  pa^ssed  i^imuhaneously,  one  into 
LCAch  09B,  and  an  attempt  umdc  to  make  them  meet  iji  the  uterus. 


202  CONGENITAL  ANOMALIES  OF  THE  ITTERUS 

If  they  do  not  meet,  tlu^  ease  is  one  of  uterus  septus.  If  the  se{>- 
tuni  (lo(»s  not  reach  to  tli(»  external  os  the  diagnosis  is  more  diffi- 
cult, and  in  this  case  the  Iow(T  edge  of  the  septum  may  possibly 
be  felt  with  the  tip  of  the  sound.  If  the  bimanual  touch  shows 
that  there  is  a  depression  in  the  fundus  we  have  to  do  with  a  case 
of  uterus  didelphys  or  uterus  bicornis,  the  latter  being  much  more 
freciuent.  The  halves  of  a  uterus  bicornis  are  commonly  closely 
adherent  well  above  the  level  of  th(»  internal  os  and  can  not  be 
moved  independently,  wluTcas  in  the  case  of  uterus  didelphys 
the  two  halves  are  \\v\l  s(»parated  and  can  be  so  moved.  They 
may  lie  even  at  some  distance  from  each  other,  and  the  point  of 
separation  may  be  felt  by  rectal  palpation,  and  if  the  conditions 
for  pa)i)ation  are  favorable,  an  ovary  attached  to  each  horn  may  be 
palpated. 

The  diagnosis  of  the  onc^horned  uterus  is  not  easy.  The  fundus 
is  found  to  one  side  of  the  p(*lvis,  it  is  tapering,  and  only  one  ovar>' 
can  b(^  made  out.  IlematouK^tra  or  pyometra  may  be  present, 
and  are  to  be  diagnoscnl  as  swellings  occupying  a  iX)rtion  of  the 
uterus.  The  diagnosis  is  difficult  and  is  seldom  made  exactly 
without  ojH^ning  the  alKlomen. 

Dififerential  Diagnosis. — It  is  important  to  distinguish  pregnancy 
in  a  detached  cornu  of  an  anomalous  utems  from  a  fibroid  tumor. 
Th(»  ()ccuiT(nic(^  of  irregular  hemorrhage  from  the  uterus  and  the 
al>senr'(^  of  the  signs  and  symptoms  of  pregnancy,  together  with 
hardness  and  irregularity  of  the  surface  of  the  tumor,  serv^e  to 
point  toward  a  filmnd. 

II.  Anomalies  Due  to  Akrest  of  Growth 

These  are  infantile  or  puerile  vteimSj  in  which  the  uterus  of  the 
adult,  remains  of  tlu^  type  found  at  birth, — and  congenital  atrophy 
of  the  uterus,  in  which  the  organ,  though  of  the  type  of  the  adult, 
is  atro|)]iied  as  a  wh()l(\  These  two  sorts  of  malformations  are 
not  V(My  uncommon.  The  condition  known  as  retroposition  with 
anteflexion  (sec^  i)age  2.'{1)  would  seem  to  be  closely  allied  to  the 
infantile  utmis. 

Infantile  Uterus. — This  is  a  relatively  conmion  condition.  The 
infantile  uterus  is  narrow  in  projjortion  to  its  length,  has  a  long 
cervix  and  a  short  body,  and  the  uterus  is  situated  well  back  and 


ANOMAUES  m-K  TO  ARREST  OF  GROWTH 


2m 


I 
I 
I 


high  in  the  [x^lvis  at  the  end  of  a  long  vagina,  there  being  at  the 
same  time  more  or  less  antrfltxion.  The  os  is  a  ** pinhole  os"  and 
the  cer\ix  is  eonieaK  Menstruation  is  usually  abstmt  in  these  eases, 
but  the  breasts,  figure,  hair,  and  vniee  may  Ix*  ]HTf(M'tly  normal; 
sexual  desire  is  absent  ami  the  patient  is  neeessarily  sterile.  The 
diagnosis  is  made  by  thr  liimnmial  recto-abdoniinal  toueh  and  by 
pa^ng  the  sound.  Thesitualionof  the  internal  os,  where  the  tij) 
of  the  mund  or  prolx*  catches,  is  well  up  in  the  total  length  of  the 
uterus  and  is  elmracteristie,  and  the  relatively  large  and  long 
cer\ix,  and  short  and  slemk-r  liody,  ean  be*  nmde  out  easih'.  The 
ovaries  are  apt  to  be  small  in  tliese  eases.  Hrlp  in  tlie  diagnosis 
L^  obtaint*<.l  often  if  th<*  utrrus  is  drawn  down  by  a  trnaeidum  h*4ii 
by  an  assistant  while  the  bituanua!  toueh  is  practiced. 

Congenital  Atrophy, — The  congenital  atrophic  uterus  is  a  rare 
condition.  Here  the  diagnosis  is  made  by  finding  a  well-|vropor- 
tioneil  utonis  w^iich  is  small  in  all  of  its  diameters.  This  anomaly 
18  a^iHociated  with  lack  of  Ixxly  growth,  absf^nre  of  |*ul>ie  hair  and 
iex  eharaeteristies.  \\v  nmst  sui»pose  that  the  individual  attained 
m  pro[K?r  growi:h  of  the  uterus  to  the  virgin  type  followcnl  by  atrophy. 
The  condition  has  Iwen  founrl  in  dwarfs  and  cretins  and  in  cases  of 
early  tulxTculosis  and  chlorosis. 

Puerperal  Atrophy, ^The  ojjjxtsite  of  subinvolution  is  puerperal 
atrophy,  superin volution.  VineU^rg  of  New  York  has  midcHl  to 
our  knowledge  of  lactation  atrophy,  (Amer,  MedicfhSni'g.  BiilL^ 
N.  Y.,  18Dri,  Via.,  1518,)  It  IS  a  shrinking  of  the  uterus  in  size 
syinnietrieally  Ix'low  the  virgin  type,  following  prolonged  lactation » 
And  is  due  prolmbly  to  overstimulation  of  the  uterus  due  to  nursing. 
It  is  not  a  permanent  condition,  the  uterus  Returning  to  its  normal 
size  two  or  three  months  after  nursing  has  bf*en  discontinued.  It 
would  appear  that  a  certain  amount  of  atmphy  is  normal  during 
the  puerfMTium  irrtsp^ctive  of  lactation,  therefoi-e  superinvolution 
is  a  distinctly  patlioIf>gical  state. 

Koo-puerperal  Atrophy. — This  oecui"s  even  more  rarely  than 
pueqieral  atrophy,  m  chronic  wasting  disi^ases,  as  in  tuberculosis, 
and  in  the  acute  infectious  dis4ms«\s^  such  as  scarlatina.  I  have 
seen  one  case  following  steaming  of  the  uterine  ca\aty.  Non- 
puerpiral  atrrjjihy  nmy  or  may  not  be  jiermanent.  The  exact 
^uses  are  not  known. 


204  L.\CERATrON   OF  THE  CERVIX   IT'ERI 


DIAGNOSIS  OF  LACERATION  OF  THE  CERVIX  UTERI 

The  credit  for  a  proixT  understanding  of  laceration  of  the  cervix 
uteri  is  due  to  Thomas  Addis  iMnmet,  of  New  York,  who  publishcnl 
his  first  pajXT  on  the  subject,  "Surgery  of  the  Cervix  Uteri,*'  in  the 
American  Journal  of  Obstetrics  in  Februar}',  1869.  Previous  to 
this  the  effects  of  lacerations  were  trc^atcMl  under  the  name  of 
ulcerations  of  the  womb,  coxcomb  granulations,  or  erosions  of 
various  sorts. 

In  a  larg(»  pro{X)rtion  of  cases  the  cervix  is  torn  during  labor, 
the  few  cases  where  it  is  injured  by  forcible  dilatation  or  incision 
at  the  hands  of  the  physician  Ixing  disregarded  here,  although  it 
happc^ns  not  at  all  infrecjuently  that  the  upjxT  ix)rtion  of  the  cervix 
is  injured  by  the  two-branchinl  steel  dilators  employed  in  dilata- 
tion for  curetting. 

Anatomy 

The  normal  cervix  in  the  virgin  is  slightly  conical  and  projects 
into  the  vagina  from  a  half  to  five-eighths  of  an  inch  (1  to  1.5  centi- 
meters). The  OS  is  round  or  oval  in  shape  and  about  a  sixteenth 
of  an  inch  in  diameter.  In  women  who  have  lx)me  children  the 
OS  is  mon*  of  a  transverse  slit  (see  Figs.  65  and  ()6)  and  may  be 
irregular  from  lacerations,  and  the  cer\ix  is  rounder  and  less  conical 
than  in  the  virgin.  To  th(»  feel  the  tissues  are  firm,  but  not  hard, 
and  seen  through  the  s[H»culum  an*  of  a  yellowish  pink  color. 
The  wall  of  the  cervical  canal  presents  anteriorly  and  posteriorly 
a  longitudinal  colunui  from  which  procecMl  a  number  of  oblique 
columns,  giving  the  appearance  of  branches  from  the  stem  of  a  tree. 
This  is  called  the  uterine  rtr/>r)r7'//a'.  These  columns  become  more 
indistinct  after  the  fii*st  lalx)r,  but  they  are  not  obliterated. 

Etiology 

Th(»  caus(»s  of  laceration  may  Ix^  enumerated  as:  (1)  A  rapid 
second  stage  of  labor,  (2)  A  large  child  and  a  small  cervix,  (3)  A 
rigid  c(Tvix,  as  in  abortion,  or  from  (Uminished  elasticity  of  the 
tissues,  (4)  Instrumentation,  as  from  th(»  forceps  or  instruments 
used  in  embryotcMuy,  or  in  dilatation,  (5)  Friability  of  the  tissues  of 


tilt'  cervix  ilui'  tu  {irolongrd  pm^sure  by  llic  pivyt^iitijig  part,  or 
tu  dii?ciii5<*  of  the  cervix. 

Mechanism  and  P  \THf)Lm;Y 


In  the  virgin  utei"iis  the  canal  of  the  cervix  at  its  widest  part, 
I.e.,  midway  Ijetween  the  (external  o.s  and  tht*  internal  os,  it^  ahoiU 
otR'-lifth  of  an  inch  in  diameter.  During  delivery  this  must  Ih: 
dilateil  to  the  diameter  of  the  child's  head,  .some  four  and  a  half 
inches.  The  muscular  fib*Ts  of  the  cervix  become  stretcheil  ex- 
ceed vely  and  it  i.s  not  surprising  that  lacerations  occur,  esj^efially 

if  insufhcient  time  is  j^ven 

for  the  dilatation.  Lacera- 
tion?* may  ix-cur  in  any  di- 
rection or  in  HO  vera!  direc- 
tions, that  is.  they  may  be 
imilateral,  l:>ilateral,  or  st la- 
bile, and  anterior  ori)oster- 
jor.  They  are  most  often 
lat4^^»ral  Extensive  tears 
which  involve  the  cervix 
above  the  attachment  of  the 
vagina  ai*e  apt  to  result  in 
iiift*ction  of  tlie  pf*rimetric 
tUsue     (cellulitis).       Dining 

jin*^iancy  the  cervix  tog(*thcr  witii  tlie  n*st  of  the  uteius  is  enlarged 
to  arcommo<late  the  grtjwiiig  fetus.  Tlie  rhythmical  contractions  of 
the  uterus  during  the  entire  pregnancy  reach  their  climax  in  labor 
when  the  major  fiart  of  the  hy|H*rtrophicrl  uterine  miiHcle  acts  as 
an  expellent  force,  while  the  small  finrtion  of  ih*  uterus,  tht*  lowii* 
part  of  the  cervix,  acts  a  imssive  r<Me  and  is  dilated.  This  lower 
part  of  the  ct*rvix  may  Ix^  likened  to  ttie  sphincter  ani  muscle. 
^fttT  reeeiviJig  an  excessive  stretcliing  as  a  pn*liminary  to  an  oper- 
tion  for  hemorrhoids,  or  other  operation  on  the  rectum,  the 
spliincter  ani  doe.s  not  recover  its  tone  and  is  unable  to  contract 
for  forty-eight  hours,  moiv  or  less — in  fact  it  has  Ix^^n  stretch**d  for 
thif^  ver>*  purI)os(^  So  in  the  ca*-^*  of  the  lowtT  cervix  after  laUir. 
It  is  ft  flabby,  Hoft  ring  tliat  ha^  no  f>ower  of  contracting.  Tfidfr 
normal  conditions,  aiul  when  not  laceratetb  it  contracts  to  the 


Fitj.  70.- 


liilat«.Tiil  T.anTations  of  lh*j  Cir- 
vix  with  Krosbns. 


L.4CE1L\T10N  OF  THE  CERVIX  UTERI 


dinietirioiis  of  a  paroui^^  normal  cervix  in  the  eourse  of  a  few  days. 
When  torn  the  lijjg  are  turned  out  into  the  \-agina  W  the  weight 
of  the  large  utcni:^  above  and  the  contracting  power  of  the  cervix 
is  thui?  loe^t.  (See  Fig.  82.)  The  intracemral  tissues  are  evert*H^I 
into  the  vagina,  the  uterine  circulation  \^  interfered  with»  the  tissues 
become  engorged  and  renuun  swollen— therefore  there  is  no  longer 
room  for  them  within  the  uterine  canal  Infection  of  the  roUed-out 
nmco^  add.s  to  the  trouble  and  erosions,  endometritis  and  cystic 
degeneration  result,  with  ultimate  thickening  of  the  torn  lips  from 
subinvolution.     Becaui?e  of  the  downwartl  excursion  of  the  hca\y 

uterus  the  cervix  projects 
relatively  farther  into  the 
vaidna  and  the  attachment*? 
of  the  latter  organ  to  the 
cervix  apjx^ar  to  Ix?  higher 
up  on  the  uterus^  although 
in  reality  they  are  not,  and 
thus  the  torn  cervix  sterns 
to  be  larger  than  it  is.  Sub- 
involution,  or  chronic  rae- 
t  ritis,  keeps  the  uterus  heavy 
and  in  this  manner  accent- 
uates the  eversion.  Lacer- 
ations of  not  great  extent 
unite  readily  in  the  abst^nce  of  infection.  If  j>el\ic  inflanunation 
is  present  lacerations  are  apt  not  to  heal  bo  soon,  if  at  all,  and 
extensive  lacerations  may  involve  the  vagina  and  even  the  bladder 
or  rectum,  leaving  fistulfle  Ix'hind  them.  It  often  happens  tliat 
the  laceration  is  in  the  canal  of  the  cer\^ix  and  that  the  external 
OS  is  little,  if  at  all,  involved. 


Via,  80. — 8t<j|latc  Lacenitioiifi  of  the  G*rvix. 


Resulib  of  Laceration 

The  imnierliatc  results  of  laceration  of  the  cervix  are  hemorrhage* 
or  the  produclioM  of  a  fistula.  The  later  result?^  are  endome- 
tritis, sul)invohition  of  thr  nteru?^,  cystic  degeni'ration  and  ero- 
sion of  the  cervix  {^h-  Clmi>tor  XL  on  endometritis,  page  184), 
thus  furnishing  a  favorable  soil  for  the  growth  of  cancer,  cellulitis 


RESULTS  OF  LACERATION 


207 


I 

I 

I 


I 
I 


Thi'8c  wt^rt^  ill  the   piT-aseptic 


(8DC  Chapter  XII.  on  pelvic  inflammation,  page  192),  cicatricial 
stenosis  of  the  ut<?rine  canal,  and  a  tendency  to  bterility  ami 
alx>rtion.  As  regard.s  the  last,  Dr,  Emract\s  tables  ('*Prinfiple8 
and  Practice  of  GTOecologj^/'  3rd  etUtion,  pages  447,  448)  show 
that  following  lacerations  of  the  cemx  71.34  [jer  cent  of  his  164 
cases  were  sterile,  and  of  the  47  who  liecame  pregnant,  51  per 
cent  alx^rted  one  or  moj^e  times. 
days  and  infection  m  a  K^i^uenee 
to  injury  was  undoubtedly  more 
frequent  than  now\ 

Endometritis    is*    eontjidercd    in 
Chapter  XI.,  jHige  165* 

Subinvolution-— Thii<  may  be  il*^ 
.fined  as  a  failure  of  tlie  physio 
'logical  hy|K^rtro|>hy  of  pregnancy 
to  mibftide  after  lab(ir.  It  is  due 
not  only  to  laceration  of  the  cervix 
but  to  ma!t)osiiion  of  the  uteru:s 
from  weakening  of  the  uterine 
ligaments  and  too  long  a  stay  in 
betl,  with  general  debility  follow- 
ing confinement,  ^Vfter  the  early  stages  of  snbinvohition  infec- 
tion plays  a  r61e  in  mosrt  ca^es  and  then*  is  present  an  interstitial 
metritis,  formerly  called  areolar  hyperi^lama.  In  this  diseas**  th(* 
conntxrtive-tissue  elementn  in  the  uterine  wall  are  increased  and 
the  muscular  elements  flirninished  In  the  acute  stages  thert^  is  a 
nJimd-eelled  infiltration;  the  utenjs  is  large  and  feels  softer.  In 
tlie  lat^T  stages  the  uterus  is  large  but  the  tissues  are  iniluratecL 
Tins  ifi  the  time  when  the  c«mneetiv^e-tissue  elements  predominate 
and  a  pathological  involution  takes  place.  The  lymph  and  blood 
vessels  are  diminished  in  sizr*,  ci-owibnl  out  by  the  conncirtive  tissue; 
the  muscle  atrophies  and  the  uterine  tissues  iK'Conie  jiale  and  in- 
durate<L  8uch  a  state  of  affairs  i?  found  in  uteri  which  have 
been  many  years  the  seat  of  chronic  metritis,  not  in  recent  eases, 
«>.,  generally  not  lx*fore  four  or  five  years  after  the  receijit  of 
jur>'  or  misplacement.  Suliin volution  or  chronic  metritis  may  be^ 
plated  with  arterio-sclerosis  of  the  uterine  vessels  in  the  later 
yeai^  of  life. 


Feg,  SL 


.*rcsccntic  Lact^ratiotis  of 

lh«*  tVrvix. 


208 


LACERATIONS  OF  THE  CERVIX   UTERI 


Diagnosis  of  Lacer.\tiox 


The  symptoms  of  laceration  of  the  cervix  are  the  symptoms  of 
the  pathological  conditions  resulting  from  this  lesion.  Immediate 
hemorrhage  following  labor  calls  for  prompt  diagnosis.  The 
sjx^cific  nervous  symptoms,  such  as  pain  in  the  suboccipital  region, 
headach(»s  of  the  vertex  and  neuralgia,  considereil  by  Dr.  Ennnc^t 
to  be  due  to  a  '*  cicatricial  plug^'  in  the  angle  between  the  lips  of 
old  tears  of  the  cervix,  are  now  generally  thought  by  the  profession 

to  be  due  to  a  deterioration  of  the 
nervous  system  caused  by  pelvic 
dis(»a^e  in  general. 

The  diagnosis  of  lacerations  is  not 
an  easy  matter,  as  l)ecomes  evident 
when  we  reflect  that  the  diagnosis  was 
not  made*  until  Emmet  showeil  the 
way  in  1862.  The  results  of  lacera- 
tions so  ol)scure  the  landmarks  that 
at  th(»  time  when  most  lacerations 
come  und(T  the  physician's  observ^a- 
tion — several  years  after  th(»ir  receipt 
— he  is  at  a  loss  to  determine  the  exact 
situation  and  extent  of  the  injur)^ 
(a)  Recent  Lacerations. — In  the  ca^* 
of  n^cent  tears  of  the  cervix  the  only 
bai-s  to  an  exact  diagnosis  are  the 
tunu^faction  of  th(»  parts  and  the  exhausted  condition  of  tho 
{)atient.  If  there  is  excessive  hemorrhage  following  delivery  the 
diagnosis  must  \}i^  made*  at  once.  In  oth(M'  cases  it  may  be  made 
in  a  few  hours  or  days,  (l(^pending  on  the  patient's  condition.  The 
woman  should  Ix'  in  the  dorsal  position  on  a  table  in  a  gooil 
light.  Tlie  perin(»um  being  n^tracted  by  a  large  Sims  speculum 
in  the  hands  of  an  assistant,  tlu*  cervix  is  seized  with  a  double 
t(*naculum  and  drawn  down  and  search  is  made  for  solution  in 
continuity  in  the  circles  of  the  enlarged  os.  Tears  can  be  repaired 
at  tliis  tine  by  suturing.  Some  operators  prefer  to  do  this  in 
an  intenn(*diat(»  tini(^,  l.c.y  four  or  five  days  after  labor,  {)erhai>s 
scraping  the  edges  of  the  tear  with  sterile   gauze  before  uniting 


Fio.  82. — Diagram  Showing 
Bilateral  Laceration  of  the  Cer- 
vix with  Eversion  of  the  Lips. 


DIAGNOSIS  OF  LACERATION 


200 


them.  The  injorie:^  must  tx^  followed  caix^fully  to  their  limits, 
whether  they  be  confin(Hi  to  the  ce.»r\ix,  or  if  they  extend  to  the 
vagina,  or  even  to  the  rertum  or  the  bladder 

(6)  Old  Lacerations.  —  If  every  woman  were  submitted  to  a 
careful  uterine  examination  after  chilil-bearing^  and  injuries  of  the 
cervix,  a.s  well  w^  thos4/  of  th(*  prhnt'  H(»or,  ffiuiid  and  n*]uiir('d,  there 
would  be  eomparatively  little  for  th(^  gviieeoioj^ist  to  do.  It  hap- 
pens, liowever,  that  most  of  tlie  laet-rations  of  the  cervix  come 
under  the  physician's  notice  for  the 
first  time  some  years  aftrT  their  tv- 
reipt.  At  tliis  time  the  dia^^nosis  is 
difficult  lxM*aui^»  of  enlargement  and 
distortion  of  the  cervix,  ev(*rsion  of 
the  l\\>^f  and  cystic  d«*generation  of 
the  Nabothian  folliclej^  and  erofsion. 
The  trame<l  vaginal  touch  after  a  littlr  /T^  ;  .^^1  '5^ 
practice  detects  all  of  tliese  features 
even  to  the  erosion.  For  inspection 
the  Sims  position  is  be^t.  Search  first 
for  the  arbor  vitre  and  thus  lieter- 
mine  the  situation  of  the  cervical 
eanah  The  pa.s,sage  of  the  sound 
helps  to  define  the  situation  of  this 
CAnal,  but  the  physician  musi.  be  otl  Fig.  S3.— Uuilateral  Lnopi-n- 
hbi  guard  not  to  Ix^  misled  by  the  tions  of  the*  Cervix,  Pro<luc-rng 
malpositions  of  tlie  uterus  fou'nd  in  Obliquity  of  the  Lon^  Avis  of  Ihe 
*  .  litems.      (Mter    Emmet.)      To© 

ca«es  of  umlateral  tear    as    pomted  Hc.jupiieation  of   the  Vagina  is 
out  by  Emrnet.     (Se<*  Fig.  83,)    In  showTiatW. 
ihU  event  the  sound   {lasscnl   to  the 

conm  opjK^tite  to  the  fM*at  of  tljc  laceration  may  appear  to  Yx^  in 
the  canal  (s(^e  figured,  but  Ixn-ause  of  the  tilting  of  the  fundus 
lowanl  the  laceration  the  stnmd  occupies  the  laceration  and  not 
the  nonnal  eemcal  canal.  Here  a  seiirch  for  the  arbor  vitie  will 
help  to  set  us  right  and  tin*  Imnanual  touch  will  also  assi:^. 
Putting  the  patient  in  the  knee-chest  pi^sitioti,  thus  jxTmitting 
the  utertLs  to  fall  towarti  \hv  afxloTTn»n  high  in  the  pelvis,  straightens 
its  axis  and  also  pulls  out  tlu^  rtHhiplication  of  the  vagina  on  the 
side  where  the  laceration  is  situatr*d.  In  all  lacerations  of  st*vere 
do  it  is  well  to  study  the  conditions  as  seen  through  the  speco- 
14 


210  DISEASES  OF  THE  UTERINE  LIGAMENTS 

luni  when  the  patient  is  in  this  position,  because  in  the  dorsal 
position  the  weight  of  the  uterus — usually  increased  in  cases  of 
laceration — drives  this  organ  downward  so  that  the  intravaginal 
portion  of  the  cervix  seems  to  be  longer,  especially  if  the  upper 
vagina  has  bc»come  stretched.  Therefore,  there  is  present  in  ex- 
tensive lacerations  of  the  cervix  apparent  hypertrophy  and  elon- 
gation of  the  cervix  lx?yond  what  really  exists.  This  reduplication 
of  the  vagina  is  showTi  at  X  in  the  figure.  Next,  with  the 
patient  in  the  Sims  position,  hook  a  tenaculum  into  the  crown  of 
each  lip  of  the  cervix  and  bringing  the  two  tenacula  together, 
try  to  reconstruct  the  cervix.  If  there  is  much  induration  of  the 
tissues  this  feat  is  difficult  of  accomplishment.  By  palpation  with 
the  tip  of  the  finger  or  the  sound,  determine  the  situation  and  extent 
of  cicatricial  tissue  in  the  angle  of  the  tear,  pressure  on  the  tissue 
causing  pain.  With  the  tip  of  the  sound  a  laceration  within  the 
canal  of  the  cervix  may  be  appreciatcnl,  for  in  that  situation  the 
sound  falls  into  an  opening  in  the  othen\ise  smooth  mucosa  of 
the  wall  of  the  canal.  The  internal  os  will  be  found  abnormally 
large  should  the  laceration  involve*  this  r(»gion,  permitting  the  sound 
to  be  moved  fnvly  al)out  after  it  has  been  passed  through. 
When  the  arbor  vitie  has  been  made  out  the  situation  of  the 
laceration  with  ref(M-onc(?  to  it  is  determined. 

DlFFKRI^XTIAL    DiAGXOSIS    OF    LACERATIONS 

Cancer  of  the  cervix  is  tin;  disease  most  often  mistaken  for  lacer- 
ated cervix.  The  (liff(M*(*ntial  diagnosis  is  considered  under  cancer 
of  the  c(Tvix,  Chapter  XVI,  page  272.  Carcinoma  is  attended  by 
much  induration  of  the  tissues  and  ulceration,  also  cancer  bleeds 
easily  and  the  superficial  portions  are  friable.  Endocervicitis  and 
erosion  is  a  coincidttnt  condition  in  laceration,  but  may  exist  in 
the  absence  of  laccM'ation.  The  diagnosis  is  based  on  the  absence 
of  the  signs  of  laceration.  Eversion  of  the  nmcous  membrane  of 
the  cervical  canal  may  be  pr(\sent  without  laceration  and  it  is  well 
to  bear  this  fact  in  inind.  The  cervix  in  such  cases  is  of  nonnal 
contour  and  there  are  no  evidences  of  laceration. 

DIAGNOSIS  OF  DISEASES  OF  THE  UTERINE  LIGAMENTS 

The  uterine  ligamcMits  an^  the  broad  ligaments,  the  round  liga- 
ments, the  utero-sacral  ligaments,  and  the  utero-ovarian  ligaments. 


THE   BROAD  LIGAMENTS 


111 


The  I3koad  Ligaments 


These  become  stretchecl  in  prolapse*  of  the  uterus  so  that  thoy  no 
longer  support  that  organ.     Under  normal  conditions  they  have 

ough  elasticity,  together  with  the  iitero-^jat'ral  H<;arnents,  to  rr*- 

ore  the  uterus  to  its  normal  ^^itnation  after  it  has  been  drawn 
do^-n  forcibly.  C'ertain  tumors  originate  in  the  broad  ligament.s, 
notably  parovarian  cysts,  filiromata  and  Ii|iomata,  also  dilatation 
of  the  veins,  varit-ocele.  The  solid  tumoi's  are  extremely  rare, 
Hpomata  are  S4*ldom  ^4t*en,  and  fibromata  only  occassional ly,  the  lat- 
ter being  not  large  as  a  rule  and  arising  in  the  unstriped  muscle  filx^r 
bt*tween  the  folds  of  the  Ugament.  Sarcoma  and  carcinoma  of  the 
broad  ligament  are  secondary  to  malignant  disease  of  the  uterus, 

Pafovarian  Cysts.— Tlicsc*  originate  in  Gartner's  duct,  Kobelt's 
tubules,  or  in  the  parovarium  projxT.  Small  peduncuJated  cysts 
may  develop  from  one  of  these  structures,  or  the  cynts  may  1k» 
s<*?s?ile  and  large.  Thest*  large  cysts,  so  called,  develop  between  the 
layers  of  the  broad  ligament  and  are  of  alow  growth.  They  are 
seMom  larger  than  a  child's  h(^a<L  The  cyst  has  no  |x?dicle,  the 
FaUopian  tube  is  stretclnHl  over  its  surface,  and  the  cyst  pushes  the 
uterus  to  the  opjxjsile  side  of  the  [K'lvis.  Adhesions  are  rare  be- 
cause the  cyst  is  covereil  by  peritoneym.  The  wall  of  the  cyst  is 
thui,  transparent,  and  of  a  gnM^nish-ycllow  hue^  the  contents  are  a 
colorless  Huid  of  a  n on- irritating  characirr  huving  a  specific 
ivity  of  lfK)2  to  1()08.  Upon  rupture  the  cj^i  is  apt  not  to  Refill, 
in  this  respect  iliffering  from  an  ovarian  cyst..  A  parovarian  cyst 
y  Ik*  raR^y  the  scat  of  papilloma  and  in  this  case  the  contents 

e  o(>acjue>  the  walls  are  thick,  and  the  (*yst  is  like  a  [mpilloniatous 
cystoma  of  the  ovary.  The  diagnosis  is  made  by  vagino-abilominal 
and  recto-ahlominal  palpation,  if  necessary  having  the  uteriLs 
ilrawn  do\ni  by  a  vuLsellum  while  the  palpation  is  being  practiced. 
(See  Fig.  125,  page  204.)  The  cyst  is  on  one  side  of  the  pelvis,  in 
close  relation  with  the  uterus.  Its  mobility  is  distinctly  limited; 
it  Is  ovoid  in  sha|)e  and  has  smooth  walls;  fluctuation  is  distinct, 
being  felt  through  tlu*  vault  of  the  vagina;  there  is  no  pfnlicle,  but 
a  groove  between  the  cyst  and  the  uterus  can  \w  distinguished. 
The  differential  diagnosis  is  considcRM^l  in  Chujiter  X\TI,  on 
ovarian  tumors,  page  2D7. 


212  DISEASES  OF  THE  tTERIXE  LIGAMENTS 

Varicocele  of  the  Broad  Ligament. — ^This  is  not  a  very  rare  disease. 
It  consists  of  dilated  veins  running  transversely  in  the  upper  part 
of  the  broad  ligament  and  forming  a  tumor  that  may  be  as  large  as 
a  small  hen's  egg,  though  generally  much  smaller.  Varicocele  is 
found  more  often  on  the  left  side.  Perhaps  this  is  because  the  left 
ovarian  vein  is  valveless  and  ojx^ns  into  the  renal  vein  at  a  right 
angle.  It  is  possible  to  make  a  diagnosis  by  recto-abdominal  palpa- 
tion by  finding  a  doughy-feeling  tumor  in  the  broad  Ugament,  but  as 
such  a  tumor  is  not  tense  except  when  the  patient  is  in  the  erect 
posture,  the  diagnostician  would  be  likely  to  miss  it  during  the 
usual  examination  made  \\'ith  the  patient  in  the  dorsal  position. 
If  there  are  varicosities  elsewhere  in  the  body  varicocele  of  the 
broad  ligament  should  come  into  the  physician's  mind  and  he 
should  examine  the  patient  in  the  standing  position.  The  char- 
acteristic symptom  of  varicocele  of  the  broad  ligament  is  a  didl 
aching  pain  in  the  pelvis  or  back. 

The  Round  Ligaments 

The  round  ligaments  var}'  much  in  size  and  in  length  in  diflF(*rent 
individuals,  therefore  their  ability  to  st(*ady  the  uterus  as  guys  is  a 
variable  quantity.  The  nuiscular  filx^rs  are  situateil  in  the  inner 
two-thirds  of  tlu^  ligament  and  sometimes  th(*  ligaments  are  nothing 
but  the  slenderest  of  cords.  Fibroma,  fil)romyoma,  adenomyoma, 
fibromyxoma,  and  sarcoma  of  the  round  ligament  have  bt^n  de- 
scrilx^d.  The  tumor  is  generally  unilateral  but  may  be  bilateral. 
These  tumors  are  thought  by  some  writers  to  be  associated  with 
fibroids  of  the  uterus.  They  may  Ix^  found  in  any  portion  of  the 
coui-sc  of  the  ligament, — in  the  alxlominal  ca\4ty,  the  inguinal 
canal,  or  in  the  labium  majus, — and  they  develop  slowly,  but  may 
be  stinuilated  to  more  rapid  growth  b}^  the  presence  of  pregnancy. 
The  tumors  are  hard  and  g(*nerally  p(*dunculated. 

Diagnosis  of  Tumors  of  the  Round  Ligament. — If  a  tumor  is  situ- 
ated within  the  peritonc^al  cavity  it  is  felt  by  bimanual  palpation 
in  the  front  of  th(^  p(^lvis  on  one  side.  If  it  is  ui  the  inguinal  canal 
or  labium  majus  the  tumor  is  felt  from  the  outside  in  the  course  of 
the  canal  or  in  the  lai)iuni.  It  must  Ix*  differentiated  from  omental 
or  ovarian  hernia,  hydrocH'K*  of  the  round  ligament,  a  cyst  of  Bar- 
tholin's gland,  or  enlarged  inguinal  lymphatic  glands.     There  is  no 


irnpuLst*  on  roughing  nr  f^traiiung  ami  tlii*  enlargement  can  nt>t  l)r 
rtMlut^cil  by  taxis.  An  (»vary  in  the  inguinal  canal  is  very  sensitive 
to  pressure,  antl  ^^wells  and  is  jiainfnl  at  the  time  of  nienstrnation. 
A  cyst  of  ]3artholin\^  gland  will  presi^nt  Hue t nation,  ami  enlarged 
inguinal  glands  are  g(*mTally  .separate  glands,  i^e.,  tliey  are  multiple 
tumors  and  are  situated  to  the  outsi<le  of  the  inguinal  eanaK 

Hydrocele  of  the  Round  Ligament  or  of  the  Canal  of  Nuck* — In  the* 
felas  the  tM'ritoneal  ('u\f'ring  of  the  round  ligament  prujects  as  a 
tubular  proee^ss  inhi  the  inguinal  canal.  Thi.s  tube  Ls  called  the 
Canal  of  Nuek  and  it  f^otnetiiTies  jx>i*sists  through  life.  If  fluid 
coll<^*ts  in  t!ii«  canal  and  the  alxiomiual  end  of  tfie  canal  is  nh!it- 
era ted  there  is  foimd  a  cystic,  translucent,  oval  tumor  which  may 
extend  do^Tiward  even  into  the  labiuin  niajus.  In  size  the  tumor 
rnay  Ix*  a*s  large  as  a  hazelnut  or  vwn  attain  the  proportions  of  a 
c«x*oanut.  It  can  not  l)e  pushetl  up  into  the  alxlomen,  it  fluctuates, 
and  ha.s  an  impulse  on  coughing  if  situated  in  the  inguinal  canal 
In  mre  ca-ses  the  cyj^tic  tumor  may  eoinmuni<*ate  with  the  peri- 
toneal cavity  and  in  this  event  the  Huid  may  he  forced  out  of  it  l>y 
gi'title  pirst^ure.  IlydnM'cle  is  not  tender  like  an  ovarian  hernia; 
it  is  of  gradual  develof)nient  and  often  there  is  ditticulty  in  rlistin- 
guishing  a  hydrocele  from  liernia.  In  the  case  <if  encysted  hydni- 
cele  the  ela^lic,  translucent  character  of  the  tumor  that  can  not 
be  reduced  with  the  jmtient  recimilx'nt,  serves  to  distinguish  it. 
The  hydrocele  that  connects  with  the  [x^ritoneal  cavity  can  not  be 
difTerentlated  from  hernia  without  an  0]jeration.  In  the  ease  of  an 
uiflarncfl  hydrocele  the  dilTereutiation  from  a  strangulated  hernia 

■  \&  made  by  the  absc^nce  of  severe  constitutional  sj^niptoms,  and 
I  of  swiptoms  of  intestinal  oKstruction,  As  a  matter  of  fact  such 
ft      tuinoni  have  generally  Ix'cn  operated  on  for  t*traEigulated  hernia. 

I  " 

■  ol 


Thk  Utero-6AcRal  Ligaments 


The  utc^ro-sacral  ligaments  contain,  lx\sides  connective  tiasue 
anil  jj€»ritoneum,  as  do  the  rounri  ligaments,  a  certain  amount 
of  nuiJHcIe  fibers.  When  tlie  uterus  is  flra\\T)  i\o\vn  forcibly  tijere 
ii*  elasticity  enough  in  the  ligament.^  to  pull  the  uterus  back  again. 
The  ligaments  are  mucli  overstretchiHl  in  prt^lapse  of  the  uterus 
and  art?  abnormally  short  in  R^troposition  with  anteflexion,  in  the 
latter  case  being  almost  of  a  cicatricial  hardness.     Naturally  liga- 


214  DISEASES  OF  THE  LTERINE  LIGAMENTS 

mcnts  of  this  character  limit  the  downward  or  forward  excursion 
of  the  uterus.  The  diagnosis  of  shortening  is  made  by  the  bi- 
manual vagino-abdominal  and  recto-abdominal  touch.  The  uterus 
is  raised  and  at  the  same  time  the  ligaments  are  palpated  to  detect 
shortening  and  thickening,  or  the  uterus  is  brought  down  by  trac- 
tion with  a  tenaculum  while  the  rectal  touch  is  practiced.  Short- 
ened ligaments  are  easier  to  make  out  than  lengthened  ones.  In 
the  infant,  the  uterus  being  very  high  in  the  pelvis,  the  utero- 
sacral  ligaments  course  from  their  origins  at  the  second  piece  of 
the  sacrum  to  their  insertions  on  the  uterus  in  the  form  of  an  arch 
and  may  be  felt  in  this  shape  by  rectal  palpation.  The  operator 
should  not  lose  the  opportmiity  afforded,  during  abdominal  opera- 
tions when  the  cul-de-sac  of  Douglas  is  in  \iew,  to  inspect  as  well 
as  to  palpate  these  ligaments  from  a^ve. 

The  Uteroovarian  Ligaments 

The  following  tumors  have  been  found  in  these  ligaments: 
fibroma,  sarcoma,  and  carcinoma.  The  last  two  must  be  regarded 
as  extensions  of  the  disease  from  the  utems;  the  former,  fibroma, 
is  very  rare.  These  tumors  can  not  be  distinguished  from  ovarian 
tumors  without  opening  the  abdomen.  In  some  cases  the  ovarian 
ligaments  are  very  long,  thus  favoring  prolapse  of  the  ovaries. 


CHAPTER  XIV 

THE  DIAGNOSIS  OF  MALPOSITIONS  OF  THE  UTERUS 

General  considcnitions,  p.  ^15, 

I.  MalfKxsiliofis  of  ihe  uk*ru.s  as  u  whole,  p.  218:  U  Ascent,  p.  218.  "i. 
Descent  (prolapse),  jn  t?18;  Patlifilog\%  p,  €18;  Mec-I»anisin.  p.  ^IJ);  S^inp- 
toins  and  course,  p.  'i'iii;  Diiignosis,  p.  'i'iC*:  Oifferenliiil  tiiagnasis,  p.  ^^K, 
S.  Anleropositron,  p.  *2^D.  4.  Latero|>osilion,  p,  "^^O.  .5.  Helro|*ositioii, 
p.  itiQ:  Retroposition  with  anteflexion,  p.  i'U ;  Diagnosis  of  relroposilion 
wilh  anteflexion,  p.  ^3^.   6,  Hernia  of  the  uterus,  p.  '2:1S, 

II,  Abnormalities  of  the  avis  ami  form  of  the  uterus,  p.  ^34:  1,  Retro- 
version, p,  i^SI;  Retroversio-flexion ,  p,  4:U;  Diagnosis  of  retroversio-flexion, 
p.  ^5tt,  €,  Anteversion,  p.  ^38.  S.  AnleflexiiMi,  p.  24U.  4.  Inversion,  p, 
^40;     Diagnosis,  p.  ^10;   Ditferential  tliagnusiji,  p- 2iO,     5.  Torsion,  p.  ^43. 


GENERAL  CONSIDERATIONS 


Ix  considering  the  subject  of  malpositions  of  the  uteriLs  it  must 
be  understood  that  tlisplai^ement  of  the  ut<*rus  carries  with  it  more 
or  less  change  in  the  position  of  other  pelvic  organs  at  the  same 
time.  For  in.'rtance,  it  is  manifestly  inipot^sible  to  place  the  uterus 
in  a  condition  of  complete*  prola|>se  without  altering  the  position 
of  the  tubo»,  ovaj'ies,  bladder,  and  vagina. 

We  shall  consider  in  each  in.stanee  the  dislocation  of  the  most 
imix>rtant  organ,  noting  the  complications.  The  normal  position 
of  the  uterus  and  thf  factors  which  determine  its  situation  in  the 
pelvis  and  limit  its  niohilily  under  the  varying  conditions  of  health 
bave  IxxTi  describe*!  in  Chapter  V.,  page  43, 

WTipn  pregnant  or  untler  condition,^  of  disease  the  uterus  is  sub- 
ject to  certain  displacements  as  a  whole,  and  its  long  axis  may  be 
tumefl  or  verted  in  one  of  several  directions.  Theoretically  wc 
have  to  do  with  two  distitict  cla.ss«_\s  of  displacements.  The  ut-erus 
may  \w  likenenl  to  a  telescope  upon  a  stan<l  in  a  room.  The  tekv 
acope  may  be  in  the  mitldle  of  the  room  (the  pelvis),  or  it  may  be 
plflccHl  against  the  wall  (rvtn>i>osition),  or  it  may  \)e  raised  (ascent), 
or  If)W(^n'd  (prubpsc*).     Also  it  mny  Ik:  tiltrii  in  one  of  many  ilirec- 

215 


21G 


MALPOSITIONS  OF  THE  UTERUS 


tions  (version)  although  its  position  as  a  whole  with  reference  to 
the  walls,  floor,  and  ceiling  of  the  room  has  not  been  changed. 

Alteration  of  the  position  of  the  uterus  generally  but  not  neces- 
sarily implies  change  in  its  axis,  and  often  in  its  form.  For  in- 
stance, retroversion  generally  means  a  certain  degree  of  retro- 
position  and  often  retroflexion;  prolapse  presupposes  retroversion 


Fig.  84. 


-Median  Section  of  the  Body  of  a  Woman  Who  has  Borne  Children. 
Bladder  Empty.    (^Schultze.)    Note  Ante  version  of  Uterus. 


in  the  early  stages  of  the  descent  of  the  uterus;  inversion  is  a  form 
of  prolapse. 

The  l(\sion  that  is  supposed  to  be  the  important  one  from  a 
pathological  standpoint  gives  the  name  to  the  displacement,  al- 
though— as  before  stated — several  lesions  are  involved.  The 
classification  here  used  is  a  practical  rather  than  a  theoretical  one. 

In  describing  the  pelvic  circulation,  Chapter  V.,  page  46,  it  has 
been  stated  that  the  blood-v(»ssels  of  the  uterus  and  broad  liga- 
ments are  convoluted,  valveless,  and  capable  of  great  distention, 
depending  for  their  normal  tone  on  absence  of  constricting  influ- 


CENERAL  CONSIDERATIONS 


21 : 


elm's  in  tht*  vviiy  v»f  i^ns^un/  from  tumoi-s  or  pelvic  mflamnuiti»rv 
maHSf^Sy  or  stR*tchhig  iluc  to  [iiaI|MisititMi  nf  tht*  ut<4"us. 

\\ i*  know  liow  much  a  nrolapso<l  utn'ius  is  nnltKHMl  in  size  aftt*r 
it  ha.s  Ix'en  rcplaecil  in  a  Jioriual  [KJsition  in  ihv  j  id  vis  and  niain- 
tairuil  there  for  a  few  hoitrs  vwn.  Wv  know  thai  a  normal  uterus^ 
clisj>lare<l  dowTiwanl  nierhanieally,  lx*<'OTries  eon^estcfL  It  is  fair 
to  iLs^smne  that  this  is  due  to  a  straightening  of  the  tortuous  valve- 


iSMTHB* 


Fia.    S4/I. — Longitudinal  MfxJian  Section  ol  a  Pd vis  with  Ovenibtcnfied  bowl- 
der    (ZuckerkandL)     Note  Retrovermon  of  Ul«rua. 

]vm  vein8,  thujs  le^^sening  the  resistance  of  their  walls  to  an  In- 
creasetl  preisaiire  delivere*!  by  the  le-sj^i  convoluted  arteries- 
It  is  the  view  of  the  author  that  uterine  nialpcjsitions  have  a 
direct  nun^hanieal  elli*i't  on  the  pelvic  cireulatiou,  therefore  ch&- 
plaeements  of  the  uterus  as  a  whole  are  of  more  importance  than 
elian^i^  in  the  axis  (version),  or  changes  in  fonn  (flexions,  torsions, 
or  tumors) • 


218  M.\LPO?mOX.S  OF  THE  UTERrS 


I.  MALPOSITIONS  OF  THE  UTERUS  AS  A  WHOLE 

1.  A-scont.  2.  Df-scont  ^prolapse).  3.  Antero-position.  4.  LateiD- 
jKTsition.    5.  Rf/tro|X)<ition.    6.  Hernia  of  the  uterus. 

1.  Ascent 

Thf*  uterus  is  in  a  position  of  ascent  in  the  later  months  of  pr^- 
iiaiK-y;  whon  it  is  displaceil  upward  by  a  tumor  developing  from 
thf?  lower  part  of  the  pelvis:  when  oversupported  by  a  pessary; 
and  when  it  lia.s  been  attachc^l  to  the  abdominal  wall  by  a  ventral 
.su.sfx.'nsion  or  fixation  ojx*ration.  The  diagnosis  is  established  by 
bimanual  palpation.  The  cer\ix  uteri  is  far  removed  from  the 
normal  situation  and  in  some  cases  can  not  be  reached  by  the  tip 
(ff  the  examiner's  finger.  The  fundus  may  be  palpated  through 
th(?  aFxlominal  walls.  According  to  our  pi'esent  knowledge  ascent 
is  not  an  imix)rtant  displacement.  The  only  sjmptom  directly 
traceable  to  ascent  is  an  irritability  of  the  bladder,  seen  occa- 
sionally, and  thought  to  be  due  to  traction  on  the  vesical  neck. 
Prolapse,  on  the  other  hand,  is  extremely  important  as  well  as  of 
common  occurrence. 

2.  Descent  or  Proiapse 

The  extent  of  the  dc^scent  varies  from  a  slight  "falling  of  the 
womb"  to  the  complete  escaix*  of  the  uterus  through  the  vulvar 
orifice. 

W'Ikii  the  uterus  remains  within  the  Ixxly  the  displacement  is 
sp(jken  of  as  an  incomplete  prolapse,  or  descensus  ut^ri;  when  it 
is  Diitsirle  the  Ixxly  it  is  known  as  complete  prolapse,  or  procidentia. 
This  form  of  (lisi)lacement  is  generally  of  slow  development — a 
matter  of  months  and  years. 

An/te  prolapse,  duc^  to  violc^nce  or  sudden  straining  when  the 
uterus  is  ]artj:e  and  heavy,  th(»  ligaments  weak,  and  the  retentive 
|)()wer  of  the  abdominal  walls  diminished — as  after  labor — has 
been  observed  as  a  rarity. 

Pathology. — The  pathology  of  prolapse  includes  the  morbid 
anatomy  of  all  the  pc^lvic  organs  involved.  The  circulation  is 
obstructed  by  traction  on  the  vessels  and  all  the  displaced  organs 


DESCENT  OR  PHOLAI^E 


2ia 


I 


I 


-■%•-/ 


«ongesteil;  tlir^  nerves  alt^  are  stretfhnti  or  even  sundf red. 
The  displaced  vagina  lK'eoni«*.s  swollen  and  conge.ste<l  and  may  bi* 
ulct"»rated;  there  may  te  hernia  of  the  ciil-de-Hac  of  Douglas,  and 
the  reetum  may  oceiisjonaliy  send  an  offshoot  into  the  hernia; 
the  bla<lder  is  frequently  displaced  anil  is  subjeet  to  catarrh;  and 
the  endometrium  is  the  seat  of  endometritis— the  uterus  being,  as 

nili%  much  conge\ste<L 

Mechanism* — To  understand  the  meehanism  of  the  production 
of  prolapse  one  must  consider  three  factors,  (a)  The  pelvic  floor, 
(b)  The  uterine  ligaments  and  attachments  of  the  uterus  to  sur- 
rounding structures,  (c)  The  variar 
tions  of  pressure  exerted  by  the 
abdominal  contents. 

(a)  Tlie  pelvic  fl<wr  is  a  muscular 
and  tendinous  diapliragm  clasing  tlie 
outlet  of  the  pelvis.  Through  this 
diaphragm  runs  the  vagina  trans- 
versi^ly  and  obliquely  as  a  slit.  In 
the  erect  woman  the  vagina  is  at  an 
angle  of  about  60°  with  the  horizon, 
tentiinating  above  at  the  neck  of  the 
womb,  which  in  turn  has  its  long 
axis  placed  at  a  right  angle  to  the 
long  axis  of  the  vagina. 

The  vagina  in  its  course  from  the 
cervix  to  the  introitus  vagina?  sliows  an  S-shaped  curve  when  seen 
in  a  median  longitudinal  section  of  the  body,  the  forw^ard  bulging 
portion  of  the  S  Wng  in  its  lower  portion  op|K)site  the  under 
edge  of  the  s>Tnphysis  pul>is*  (See  Fig.  85.)  Tliis  prominent 
portion  of  the  vagina  is  made  by  the  presence  at  this  jioint  of 
the  chief  muscle  masst*s  of  the  levator  ani  and  smaller  muscles 

,d  fasciie  making  U[>  the  pelvic  floor.    It  is  the  socalled  "  ]jerineal 

iy'*  of  the  older  g>^necoIogists,  By  reference  to  the  diagram 
(Fig.  84)  it  mH  be  seen  that  this  key-stone  to  the  airh  of  the  pelvic 
diaphragm  lies  about  midway  lx»tween  the  lower  border  of  the 
^Tiiphysis  and  the  Cixrcyx.  Injury  to  the  muscles  here  naturally 
d<'stro>^  the  sigmoid  curv^e  of  the  vagina,  opens  its  outlet,  and 
diminishes  the  support  to  the  structures  lying  alx)ve.  The  vagina, 
instead  of  being  a  flattened  ribton-like  canal  with  walls  in  apposi- 


FiG.   85. — S-ehuped  Curve  and 

IncUnation  of  Vagina.  Not«  that 
the  Walk  Are  iu  Apposition. 
(Sltene.) 


220  MALPr^srru»xs  of  the  iteris 

tion  aiitl  niiiniii^  alnn»>t  tniii-v«rs<'ly  fnmi  thi*("«»mx  to  the  hymen, 
nnw  Ui-oniis  a  >trait:htrr  o|m-ii  tuU\  Ifailiiii;  ahiMi<t  ilinftly  ilown- 
wanl  from  thr  crmx  to  th«*  i;itri»itu>. 

The  jK-lvic  flfM»r.  a<x-un!mg  to  Hart  an«l  Barlx>ur,  may  be  cli\i<l(Hl 
up  into  an  anti'rior  anil  a  jK>sterior  si'gment.  The  anterior  s<^g- 
ment  is  a  n-lalivfly  movablr  one,  the  po>-terior  is  relatively  fixe<l. 
The  ant<Tior  or  puhic  s4-irni(.nt  consists  of  anterior  vaginal  wall. 
un*thra.  an<l  l»hi<H«T.  all  attacluil  l(K)s«'ly  to  the  sjTiiphysis  pubis 
by  n-tn^pubic  <lejK)>its  of  fat.  The  |)osterior  or  sacral  .segment 
is  niaile  up  of  j)ost«Ti<»r  va^nal  wall,  the  muscles  and  fasciae  of 
the  |M'rineum,  an«l  tlu*  nK-tuni.  all  finnly  liouml  to  the  sacrum  and 
coccyx.  During  lal>or  the  anterior  segment  is  ilrawn  up:  the 
|XJsterior  segin<'nt  is  <lriven  down.  In  the  formation  of  prolaps* 
the  anterior  s<gnient.  l^i^cause  of  the  injure'  of  the  posterior  seg- 
ment, swing<  downward  antl  l)ackwanl — the  retropubic  fat  giving 
way  with  consiMpirnt  dislrwation  of  bladder  and  urethra.  It  is 
I>lain  that  a  tipping  back  of  th<'  uterus  on  its  axis,  so  that  it  may 
^et  into  the  siinie  axis  as  the  vagina,  is  a  n-^juisite  to  the  descent 
of  that  organ,  and  that  this  tipping  Iwckwanl  is  made  passible  by 
injur}'  of  the  jM)st(Tior  segment  of  th(»  jK»lvic  floor  and  dislocation 
of  the  ant(Tior  s<»gnient,  so  that  the  cer\ix — not  stayed  from  lx»- 
hind  and  havnig  no  firm  tissue  in  front  of  it— swings  fonvanl  until 
its  long  axis  coincides  with  the  long  axis  of  the  vagina.  This 
subject  will  Ik'  made  clearer  when  we  consider  the  different  direc- 
tions in  which  under  varying  conditions  the  intra-abdominal 
pressure  is  applie'd  to  the  fundus  uteri. 

ih)  Tlie  utcrinr  lijranirnt<  and  the  attachments  of  the  uterus  to 
the  surrounding  stnicturcs. 

The  litianicnts,  descrilx-d  in  (1mpt(T  V,  page  44,  consist  of 
three  pairs  ()f  ligaments  projKT — the  broad,  the  romid,  and  the 
utero-saeral ;  and  the  attaehments  an^ — the  utero-vesical  conm»c- 
tive  ti.-sue,  the  va«iina,  and  the  retro-uterine  cellular  tissue.  In 
eonsi(lerin<:  the  causation  of  prolapse  we  must  think  of  the  woman 
Ix'ing  in  the  erect  position,  l.>ecaus(»  it  is  in  this  attitude  that  the 
great  strain  is  hrouiiht  to  l)ear  that  causers  sacro-pubic  hernia. 
Hy  referen^-e  to  tlie  diatrrani  (Fi<r.  .S4)  on  page  21G  it  will  lx»  seen 
that  the  origins  and  insei-tions  of  all  tlu»  ligaments  lie  in  nearly 
the  same  plane.  As  a  matter  of  fact,  the  pubic  ends  of  the  nmnd 
ligaments  are  a  little  lower  than  their  insertions  into  the  horns  of 


DESCENT  on   PROLAPSE 


221 


thr  litems,  then?fore  the  roimd  ligaments  can  not  support,  the* 
uteras  except  in  casct*  of  extreme  prolapse.  Oii  the  other  ham  I, 
the  attachments  of  the  utcrosacra!  li^anient.^  to  tiie  jielvir  wall 
near  the  second  piece  of  the  i^aeruni  are  a  triiie  higher  than  tlieir 
insertions  into  the  uterus  at  the  level  of  the  internal  os.  They 
are  nomially  firm  and  i^trong  and  act  a.*?  true  su|>[K)rts. 

The  broad  hiranieiits  elu^ck  laternl  motion  and  liniit  tfie  uterine 


If 

"^"-  n 

1  ^H 

V   '''                            ^^flM  ■ '  J 

fkriHixi 

/f**^^— .-wl 

'^^  nh 

mfSiai^mjf  Mielf     -1 

O*^^  ilf*tfn  -^0! 

^^^^^^^H^^Hy^H  «A 

\ 

'^^■ji       ^  '1 

f 

Fia.  86.— Right  Hide  of  AWommaJ  Wivil  lliw  Btx^ri  Remo\t^i.  8howtrig  Fun* 
I  Shajicof  AhKlnminal  Cavity » whk'h  I«  Wide  Above  aud  Narrow  lie  low,  aUo  ih^ 
ating  Shelf  which  (ii%<.'s  Partial  tSupport  to  the  V'iscern.     i Alter  Corning.) 

niovemfmt.H  largely  to  fonvard  antl  liaekward  excursions.  The 
intra-ablominal  prc^ssure  is  exertitl  on  the  posterior  a*^p(*et  f>f  their 
bn^ail  surfaces  and  then^w  tli<*y  assisrt  either  in  retaining  the 
ulenis  in  ai»teversion,  or.  if  th**  axis  of  th<'  uterus  h^  lxH*n  changed 
from  anteversion  to  n*troversion,  the  pressure  Ix'ing  on  their 
posterior  ai?peets>  they  assist  in  ke<*ping  the  woinh  in  that  position 
and  in  aiding  prolapse.    The  thick  basics  of  tlie  broad  ligaments 


222  MALPOSITIONS  OF  THE  UTERUS 

intimately  joinc^l  with  the  uterus  form  strong  connecting  and 
supix)rtiiig  structiux^  between  the  uterus  and  pelvic  walls.  Pro- 
lapse can  not  occur  miless  the  attachments  of  the  ligaments  or  the 
ligaments  themselves  arc  severed  or  stretched.  The  utcro-vesical 
connective  tissue,  when  torn  asunder  by  labor  or  when  weakeneil 
by  the  atrophy  of  the  triangular  mass  of  subpubic  fat,  promotes 
retroversion  and  also  i)rolapse  by  lessening  the  resisting  power 
of  the  structun^s  connecting  the  uterus  with  the  symphysis  and 
indirectly  diminishing  the  distance  between  the  cervix  and  the 
pub(^s. 

One  of  the  common  n^sults  of  a  difficult  labor  is  to  loosen  the 
attachments  of  the  vagina  to  the  cer^'ix.  As  seen  through  a 
speculum  with  the  patient  in  the  Sims  or  knee-chest  position,  there 
appears  to  be  little  or  no  intra-vaginal  portion  to  the  cervix.  In 
these  cases  the  mobility  of  the  uterus  is  increased  and,  other  things 
being  ec|ual,  descensus  is  favored.  The  attachments  of  the  vagina 
to  the  ccTvix  si^ve  to  steady  the  uterus  and  keep  it  in  its  proper 
relation  to  the  pelvic  floor. 

The  retro-uterine  c(^llular  tissue  has  probably  very  little  influ- 
ence on  tlu^  position  of  the  utcTus  unless  it  is  the  seat  of  inflamma- 
tory thickening;  in  which  case  it  fixes  the  organ.  It  sometimes 
happens  that  wonuMi  who  are  the*  subjects  of  pelvic  inflammation 
are  relieved  of  pnM'xisting  i)rolapse  only  to  suffer  with  it  again 
when  the  exudate  has  l^^en  al)sorb(Ml. 

(c)  The  variations  of  pr(\'=^sure  exert eil  by  the  abdominal  con- 
t(Mits.  Tli(^  Holder  is  referred  to  Chapter  V.,  page  45,  for  a  partiid 
exposition  of  this  sul)je('t.  Here  it  is  sufficient  to  say  that  we  have 
to  do  with  (1)  downward  ])ressun^  exerted  by  (a)  increased  weight 
of  the  nicms  itsi^lf,  {b)  the  weight  of  the  intestines  filled  with  a 
varying  amount  of  solid,  fluid,  or  gaseous  matter,  and  (c)  the 
weight  of  dislocated  organs,  such  as  the  stomach  or  kidneys,  or 
the  w(»i»:lit  of  a  tumor;  and  (2)  additional  pressure  transmitted  to 
the  abdominal  contents  by  the  walls  of  the  abdomen  and  by  the 
diaphragm  in  contrliing,  laughing,  straining,  jumping,  and  riding. 

The  downward  pn\<sur(^  spends  itself  under  normal  conditions 
mostly  on  the  lower  anterior  wall  of  the  alxlomen.  By  consulting 
Fig.  G,  page  44,  it  is  apparent  that  the  long  axis  of  the  abdominal 
cavity  falls  at  nearly  a  right  anglt^  to  the  long  axis  of  the  pelvic 
cavity,  and  that  the  pelvic  viscera  are  protected  in  a  measure  from 


DESCENl'  OR  PROLAPSE 


223 


IMWure  directed  tlownwai'd  from  above  by  thr  forward  liuiibar 

curve  of  the  spine,  which,  in  the  normal  standing  posture  of  the 

individual,  must  take  8omc  of  the  weight  of  the  contents  of  the 

alxiomen.     A  transvense  .sectiim  of  the  body  of  tlie  Mlult  virgin 

through  the  fifth  lumbar  vertebra  ^hows  that  at  this  situation  the 

depth  of  the  aklominal  cavity  f  1*0111  before  back  is  ver^'  much  le^ 

than  it  i^  in  the  upper  portion  of 

the  alxlomen*    For  instance,  it  rej>- 

rt*?jents  only  a  little  over  a   third 

of  the  entin*  thickneas  of  the  liody 

if  measured  in  the  nuxtian  line  fnmi 

the  anterior  face  of  the  lumbar  ver- 

tebm  to  the  ^kin  j>urface8  of   the 

front  and  Ijack  of  the  l>ody.    At 

the  level  of  the  twelfth  doi-yal  ver- 

t4*bra,   on    the    other    hand,    the 

abtloniinal  ca\'ity  takes  up  over  a 

half  of  the  tliicknesB  of  the  trunk 

if  meai^iurd  in  the  same  way  and 

occupies  a  major  part  of  the  cubic* 

contents  of  the  Ixxly  at  this  jmint. 

When  tlie  Iwu'k  is  flatternd  and 
the  forward  luml>ar  curve  is  more 
or  le«s  oblitrratcMl^as  happens  in 
the  cajseof  the  tlat^hested,  slouch) 
body  |X)sture  so  often  seen  inwonjcn 
— more  of  the  weight  of  the  \iseera 
will  fall  on  the  inlet  of  the  |X'lviH, 

Under  normal  conditions  there 
is  prewnt  a  thru^st  directed  forw^ard,  inward,  and  do\\Tiward  from 
thi?  slanting  surface  of  the  brim  of  the  false  pelvis  (60°  with  the 
horizon!  that  throws  the  abdominal  pressure  on  to  not  only  the 
Jow*er  alHlominal  wall,  but  also  on  ti»the  posterit^r  surface  of  the 
anteverted  uterus  and  the  backs  of  the  wide  expanses  of  the  broa4:i 
ligaments,  Tlius  is  the  uterus  maintained  normally  with  its  long 
axis  at  a  right  angle  at  least  with  the  long  axis  of  the  vagina. 
Ab  has  been  stat(»d  previously*  the  axis  (»f  the  utenis  must  be 
■     chaiige^^l  to  retroversion  t»efore  prolapH"  can  occur.    Such  a  diangc* 


Procidentia. 


MpH  tr    Prulapse    or 
t After  Huguier.) 


224 


3L\LPOSmONS  OF  THE  UTERUS 


chronic  (Ii.stention  of  the  urinan'  bladder,  chronic  fukiess  of  the 
rectum,  sudden  jar,  etc.  (s^ee  Retroversion,  pwige  234).  When 
once  th<»  axis  has  been  changed,  the  intra-abdominal  pressure  is  ex- 
erterl  against  the  anterior  face  of  the  uterus  and  the  broad  liga- 
ments, and  increased  pressure  accentuates  the  retroversion,  and  at 
the  same  time  pushes  down  the  uterus,  now  in  the  same  axis  as 
the  vagina.  Factors  which  make  for  greater  downward  pressure, 
such  as  a  jK'rsistent  cough  or  violent  straining  because  of  chronic 


Fig.  H8.— Prolapse  of  the  Va^iii:i  and  Cervix,  with  Elongation  of  the  Supra- 
vaginal Cervix. 


diarrhea,  tend  to  cause  descensus  uteri.  Constant  straining  is  an 
important  faetor  in  the  causation  of  prolapse;  therefore  prola|)se 
is  found  most  freriuently  among  women  of  the  working  classics. 
These  women  an^  apt  to  gc^t  up  and  Ix^gin  work  soon  after  con- 
finement wlu^n  the  uterus  is  large  and  heavy  and  retrovert^d. 

Inversion  of  \]w  vagina  may  take  place  without  actual  descent 
of  the  ut(Tus  because  of  the  elasticity  of  the  vagina,  and,  prolapse 
may  Ix^  simulated  by  elongation  of  the  lower  uterine  segment. 


DESC'EXT  OR  PRuLAPSE 


225 


True  hiffferlnrphi4'  elongation  of  the  cervix j  a  lengthening  of  the 
I    cervix  and  the  lower  segment  of  the  uterus,  is  by  no  means  an 

uneomTnon  condition.     In  such   a  ea-^e,  should   the   utero-pacral 

liganiexit.s,  which  ordinarily  limit  the  amount  of  the  descent  of  the 
I   uUtus,  prove  to  be  strong  and  not  susceptible  of  stretching,  the 

fundus  uteri  may  remain  nrarly  at  its  normal  level  whili^  the  exter- 

Jiml  OS  presents  at  the  introitui?  vaginie.  A  typical  vasi^  of  true  hyper- 
tropic  elongation  of  the  cervix  was  n.^ijorte*!  by  Hugnier  (**Mcmoire 
sur    les   Allongements    Hypertrophiques   du    Col    de    TUt^Jrus," 


iLJi 


d 


Fig.  S8a. — Hypertrophic  Elongation  of  the  Cervix  in  the  Virgin, 


,18641,  p.  40)  as  long  a^r*  sis  lSf»0.  A  woman  tw(*nty-three  years  of 
?,  of  poor  general  health  an<i  physiijui*,  married  two  years  but 
never  pregnant,  pre^sented  hersi^f  for  tn»atment  because  of  pains 
in  the  abloinen,  dyspareunia,  and  a  tnmor  in  the  opening  of  the 
vagina.  Catamenia  began  at  thirkrn  and  she  noticed  the  pro- 
jection at  the  vulva  at  fourtii  n  anil  a  half  yeai-s.  It  came  out 
while  she  was  staniling  or  straining  and  was  rcHluced  on  lying 
down*  Examination  showetl  the  vagina  only  a  little  ^^hoilened  ami 
£!Upic»fl  by  the  enlargal  cervix;  fundus  uteri  only  a  trifle  below  its 


226  MALPOSITIONS  OF  THE  UTERUS 

normal  situation;  and  the  uterine  cavity  measured  five  inches  (13 
centimeters)  in  depth. 

Prolapse  is  largely  a  disease  of  women  who  have  borne  children. 
It  is  most  conmion  after  the  menopause  when  the  utero-sacral 
ligaments  are  prone  to  be  fatty  degenerated,  the  other  supports 
of  tlie  uterus  have  lost  their  tone,  and  there  is  increased  abdominal 
pn^ssure  due  to  increase  in  the  size  of  the  abdominal  contents.  It 
occurs  hifrecjuently  in  the  nulliparous  woman  and  is  then  com- 
monly due  to  retroversion  associated  with  chronic  diarrhea  or  a 
long  standing  cough;  or  to  incn^ase  of  alxlominal  pressure  from 
ascites  or  a  tumor.  It  is  probable  that  stretching  of  the  utero- 
sacral  ligaments  and  a  conse(|U(»nt  carrying  forward  of  the  cervix 
may  r(\^ult  from  chronic  fecal  impaction  of  the  rectum. 

Symptoms  and  Course  of  Prolapse. — ^I'he  usual  symptoms  of  pro- 
lapses are:  Dragging  pains  in  the  pelvic  region  and  difficulty  in 
walking;  frequ(»ncy  of  micturition  and  v(*sical  tenesmus;  inability 
to  empty  the  rectum;  leucorrhea,  irritation,  and  pain  from  vaginitis 
or  an  ulcerated  vagina;  and  stcTility.  It  may  be  necessary  for  the 
patient  to  stay  in  IxhI  in  severe  cases — often  all  hard  labor  has  to 
bc^  givcMi  up.  The  course  of  the  disease  is  chronic  as  a  rule,  though 
not  hifn^quently  complicated  by  attacks  of  acute  vaginitis.  Occa- 
sionally an  attack  of  peritonitis,  by  making  adhesions  and  thus 
fixing  tlu^  uterus,  has  Ikhii  known  to  (effect  a  cure. 

Diagnosis  of  Prolapse. — In  establishing  the  diagnosis  of  prolapse 
we  considcT  the  clinical  history,  and,  in  a  less  degree,  the  symptoms. 
Th(»  woman  is  gen(Tally  at  the  menopause  or  has  passed  it,  is  the 
mother  of  one  or  mon^  children,  and  belongs  to  the  working  classc»s. 
There  is  ordinarily  a  history  of  a  preccMling  uterine  malposition,  such 
as  retrov(Tsion.  Tlus  appearance  of  a  protrusion  at  the  vulva  on 
straining  at  stool  or  on  oth(T  ex(M-tion  is  often  a  sudden  affair  and 
may  be  th(^  first  abnormality  noticcnl.  The  cervix  is  disthigiiished 
from  rect()C(^l(\  cystocele,  cysts  of  the  vagina,  a  fibroid  polyp,  or 
inverted  uterus  by  tlu*  pr(\^(Mice  of  the  os  externum.  When  the 
prolapses  is  established,  the  patient  complains  of  pelvic  pains, 
dysuria  or  fnuiuent  micturition,  difficult  locomotion,  and,  if  the 
rectum  is  involved  in  th(»  descent,  of  inability  to  evaeruate  the 
bowel  without  assistance  from  th(*  hand.  There  may  be  inconti- 
nences of  urine  from  overdistention  of  the  bladder,  and  the  pnv 
la{)sed  mass  may  become  ulcerated  from  attrition — in  this  cast* 


Frr..  89.  -  Partial  Prohipw  of  the  Ithruriaud  \  agin  a.  I  Iju  Lj^hl  t^pot  »SJiou,*> 
l}i«'  8it  lint  ion  of  th«-  Tip  of  a  Suumi  ia  the  Biudder,  Marking  the  Lowest  Pomt 
of  the  Blttdrl<?r.     (Kelly) 

If  the  j>rolapsi»  is  only  partial  an  examination  in  the  standing 
pr>:*ition  i^hoiiIJ  tx*  mmh  nlsn.  the  [mti<^nt  t Hearing  tlmvn  so  a^s  to 
«irivc!  out  thr  h<Tnia  to  its  full  exti'nt.  TIhtc  is  i^Mom  much 
^Uffieulty  in  making  tht*  diaKunsis,  Tlit-  iTuportant  points  are  to 
*letprmiiir  Ihr  t*xtpnt  of  tin*  ilownwani  dii^loralion  of  tlic  uterus*: 
iho  rxact  she,  position,  and  shape  of  this  organ;  the  {situation 


228  MALPOSITIONS  OF  THE  UTERUS 

of  bladder,  urethra,  and  rectum — also  the  ovaries  and  tubes — 
and  the  amount  of  prolai)se  and  the  condition  of  the  vagina.  In 
most  causes  of  prolap^^o  the*  vagina  becomes  thickened  to  a  marked 
degrt'e  and  takes  on  the  characteristic  of  skin,  and  ulceration  may 
develop  in  its  structun^s.  These  items  are  to  be  noted  carefully 
because  upon  th(»ni  depc^ncLs  the  form  of  treatment  employed  and 
its  success. 

A  conjoined  recto-ab<lominal  examination  determines  the  situ- 
ation of  the  fundus  uteri.  A  sound  passed  into  the  uterine  cavity 
shows  its  d(»pth,  size,  and  shajx?,  and  whether  or  not  any  polypi  are 
situated  th(»re.  The  cleans(»il  sound  passed  into  the  urethra  shows 
the  direction  of  the  canal  and  whether  any  portion  of  it  is  dislo- 
cated do\Miwanl  and,  if  so,  how  much.  It  also  shows  the  limits 
of  the  bladder  in  the  prolapscnl  mass  by  noting  the  situation  of  the 
point  of  the  sound  on  the  vagina  both  by  sight  and  touch.  (Sec 
high  light  in  Fig.  89,  marking  tip  of  sound  in  bladder.)  A  finger 
hooked  through  the  anus  .shows  whether  the  rectum  has  been  dis- 
located downward.  It  may  Ix^  possible  to  palpate  the  whole  of 
the  uterus  outside  the  vulva  through  the  walls  of  the  inverted 
vagina,  but  in  most  cas(»s,  for  the  purjXDses  of  diagnosis,  it  Is  best  to 
reduce  tin*  prolaps(\  This  is  done  by  covering  it  with  muco- 
lubricans  and  making  g(»ntle  upward  pn^ssure,  at  the  same  time 
squeezing  the  mass  a  littl(%  and  in  some  castas  it  may  be  necessary 
to  place  th(»  patient  in  th(»  knee-chest  position  before  resorting  to 
this  nu^asure.  When  the  mass  has  been  reduced  a  bimanual  ex- 
amination is  made  with  the  patient  in  the  dorsal  position  and  the 
size  and  shape  of  the  utcTus  mappc^d  out  anew.  It  is  now  possible 
to  (letennin(»  true  hypei-trophie  (^longation  of  the  lower  segment 
of  the  uterus,  fibroid  no(lul(\^,  the  location  of  the  ovaries,  etc.  If 
th(^  vaginal  walls  are  much  thickened  the  tactile  sense  of  the  ex- 
aminer's finger  will  Ix^  blunted.  In  this  event  a  recto-abdominal 
examination  will  i)rove  to  Ix^  more  satisfactory. 

Differential  Diagnosis  of  Prolapse. — An  inverted  iderus  may  be 
mistaken  for  a  prolapse.  The  absence  of  a  distinct  ring  having  a 
sharp  edge  coni{)letely  surrounding  the  i)rolapsed  mass,  and  the 
fact  that  at  no  {)oint  can  a  sound  be  passed  into  the  tumor,  sen'c 
to  distinguish  the  two.  If  th(*  alxlominal  walk  happen  to  be  ex- 
treuK^y  thin  a  eui>shaped  deprc^ssion  in  the  abdominal  aspect  of 
an  inverted  uterus  may  be  made  out  by  bimanual  touch. 


True  hypertrophic  elongation  of  tlie  lower  uterine  segment  (Fig,  88a) 
has  been  spoken  of  as  a  part  of  prolapse.  It  is  clijignosed  by  cli&- 
tingui.shing  unusual  k*ngth  of  ttie  lowrr  part  of  tin*  uterus  by  bi- 
manual touch,  by  finding  a  fundus  placed  relatively  high  in  the 
pelvis,  and  Increasixl  length  of  the  cervical  canal,  as  disclosed  by 
in«ii<uring  the  sound  passed  only  to  the  internal  os, — the  point 
where  the  tip  meets  an  obstruction.  Wlien  the  |mtient  is  placed 
in  the  knee-eh(»st  |>osition  the  cervix  18  not  obliteratcHl,  as  under 
normal  conditions.  True  hypertrophic  elongation  occurs  only  in 
sterile  women;  falst^  hy|)ertrophic  elongation,  occurringin  the  i>arous, 
is  ilescribed  in  the  chapter  on  laceration  of  the  cervix,  page  209. 

A  pedunculated  fibroid  or  polypm  is  sometimes  mistaken  for  a 
prolapse.  In  this  case  a  soimd  can  be  swept  about  in  the  uterine 
cavity  at  any  point  in  the  circumference  of  the  collar  of  the  cer\ix 
except  at  the  side  wliere  the  polypus  is  attached  to  the  literine  wall. 
There  is  no  cavity  in  the  polypus,  and  recto-ablominal  touch  re- 
veals the  presence  of  the  fundus  uteri  in  its  normal  position. 


I 


t 


3.  Antkrofosition 

Anteroposition  of  the  uterus,  or  a  utenis  jilaced  as  a  whole  too 
near  the  symphysis  jjubis,  is  due  to  retro-utiTine  tumors,  such  a^  a 
pehic  hematocele,  dermoid  ovarian  tumor,  or  tumor  of  the  rectum, 
or  even  an  overloaded  rectum.  As  far  a^  we  know,  this  position 
of  the  uterus  is  of  no  significance  from  a  pathological  or  clinical 
point  of  view.  The  diagnosis  is  established  l)y  the  bimanual 
touch;  noting  that  the  uterus  is  not  in  its  normal  situation  but 
dose  against  the  pubic  arch, 

4.  Lateroposition 

f 

The  uterus  may  be  displaced  to  the  right  side  or  to  the  left  side 
by  a  tumor  or  an  inflammatory  mass,  the  uterus  Ixnug  puslied  to 
the  opposite*  side  of  the  pelvis  to  that  occupietl  by  the  tumor  mass. 
CiciUricial  contraction  folloviing  an  effusion  in  one  Ijroad  ligament 
may  draw  the  uterus  to  that  side  of  the  [X'his.  Such  a  malposi- 
tion is  to  be  noted  for  the  purpose  of  removing  its  cause  and 
hae  significance  only  because  of  the  jmthological  condition  pro- 
ducing it. 


230 


MALPOSITIONS  OF  THE  UTERUS 


o.  Rktroposition 

This  is  an  important  malposition  which  is  almost  always  attended 
by  dysmenorrhi^a.  It  is  often  spoken  of  as  retroversion  and  also 
as  anteflexion.  Dissimilar  as  these  abnormalities  api>ear  to  be, 
th(Te  are  comparatively  few  cas(\s  of  retroversion  or  anteflexion 
that  do  not  have  a  certain  amount  of  retroposition.  The  placmg 
of  the  uterus  backwanl  near  the  sacrum  seems  to  be  the  important 


Fig.  90.— Anteflexion  in  the  Little  Girl.     (Schultze.) 

factor  in  the  causation  of  symptoms.  The  immobility  of  the  uterus 
in  this  position  is  undoubtcnlly  the  chief  factor  in  the  causation  of  a 
large  class  of  cases  of  antc^Hexion,  and  the  fixity  of  the  organ  close  to 
the  hollow  of  the  sacrum,  rather  than  its  anteflexion,  is  the  deter- 
mining elcMiient  in  the  production  of  the  symptoms  from  which 
patients  with  these  abn()rmaliti(\^  suffer.  The  retropositions  asso- 
ciat(Hl  with  retroversion  will  be  taken  up  under  the  head  of  retro- 
version. Here  we  will  discuss  the  very  common  uterine  disease, 
retroposition  with  antc^flexion. 


RCTRcmxsmoN  231 

Retroposition  with  Anteflexion.— By  reference  to  tlir  figure 
taken  from  IIS.  Shultze^  '*  Displaeenients  of  the  ri(^ruH/*  Fig.  90, 
it  will  h'  note4  that  in  the  little  girl — the  bladtler  and  reetuin  Ixing 
empty — the  uterus  Ls  normally  in  a  state  of  anteflexion;  that  the 
vagina  is  relatively  long;  the  long  axis  of  the  cervix — also  long  with 
refen*nce  to  the  k*ngth  of  the*  corpus — \^  nearly  in  the  axiij  of  the 
vagina;  the  intravaginal   anterif>r  \\p  of  the  cervix  is  short;  and 


■^ 


I 

Fio.  dl. — Pathological  Anteflexion  Arising  from  Coatmction  of  the  I'tero- 
LigatnenU      {a)  Dirt-rHoD  of  flit*  l*iill  t»f  rhe  Ligaments.     (6)  Direction 
P^fbo  Intra-abiloniinal  Pressure.     tScliuItste. ) 

the  n^gion  c»f  the  internal  os  is  high  up,  Ixthusc  the  entire  ntt*rns  is 
in  the  falw^  peKis,  and  is  near  the  sacrum.  The  ntenis  is  not  fixeilp 
howrver,  in  this  [josition*  Tiiis  condition,  then,  is  nomml  to  the 
growing  girl  li^fon*  lailxTty, 

Fig.  91  shows  retroiMisition  with  anteflexion,  the  old  so- 
callini  *- pathological  anteflexion/'  The  siniilarity  of  the  two 
conditions  is  striking,  and  it  seems  fair  to  draw  the  inference  that 
retroi)08ition  with  anteflexion  is  a  pc*rsistence  of  the  puerile  stat<*. 


232  MALPOSITIONS  OF  THE  UTERUS 

with  the  addition,  in  the  case  of  retroposition  with  anteflexion,  of 
adhesions  limiting  the  mobility  of  the  uterus. 

Anteflexion  may  be  accjuired,  however,  as  in  the  case  of  a  uterus 
with  softened  tissues  having  a  fibroid  in  the  anterior  w^all  of  the 
fundus.  Excessive  straining  at  stool  tends  to  bend  the  cervix 
forward  and  at  the  same  time  to  fold  the  fundus  and  body  of  the 
uterus  forward  and  downward,  pro\nded  the  forward  excursion 
of  the  region  of  the  internal  os  is  limited.  Thus  a  flexed  uterus 
becomes  more  flexed.  The  uterine  caiial  is  obstructed  mechan- 
ically at  the  internal  os  by  excessive  flexure,  therefore  we  should 
expect  these  patic^its  to  suff(T  with  blood  stasis  and  endometritis, 
the  results  of  a  damming  up  and  d(*composition  of  the  uterine  dis- 
charges, and  this  is  usually  the  case. 

Vesical  symptoms  aiv  due  to  the  backward  traction  of  the  cervix 
on  the  vesical  neck  and  to  the*  interference  offered  by  the  forward 
flexed  fundus  uteri  to  the  filling  of  the  bladder.  Of  the  two  the 
former  is  the  more  important  cause. 

I  have  previously  callcnl  attention  to  the  frequency  of  retro- 
position  with  anteflexion  ('^Division  of  the  Utero-Sacral  Liga- 
ments and  Suspensio  Uteri  for  Immobile  Retroposition  with  Ante- 
flexion,'' Ainer.  Gyn.  and  Ohstet.  Joiir.y  Jan.,  1898,  and  '^Furthtjr 
Experi(*nce  with  th(^  Operative  Tn^atment  of  Anteflexion,''  Arner. 
Gyn.  and  Ohstet.  Jour.y  Jan.,  19(M)).  The  condition  has  not  been 
recognized  g(*nerally  by  the  profession,  having  been  classed  broadly 
SiS  retrovi^rsion. 

Diagnosis  of  Retropos^ilian  with  Anteflexion. — ^The  diagnosis  is 
made  by  finding  the  uterus  as  a  whole  in  the  extreme  back  part  of 
the  pelvis.  This  is  doru?  by  practising  the  bimanual  vagino- 
alxlominal  or  recto-alxlominal  touch.  The  cervix  is  in  the  axis 
of  the  vagina,  the  anterior  lip  is  flattened  and  short,  the  crown  of 
the  cervix  being  in  extreme  cases  practically  continuous  with  the 
front  wall  of  the  vagina.  The  cervix,  in  the  axis  of  the  vagina,  is 
not  so  long,  a.s  a  rule,  as  in  the  case  of  the  puerile  cervix,  but  it  is 
long  as  compared  with  tlu^  fundus,  representing  two-thirds  of  the 
entire  length  of  the  uterus.  Its  tissues  are  generally  indurated 
and  more  or  less  tcnider;  there  is  a  cervical  discharge  from  a  pin- 
hole OS.  The  fundus  is  flexed  fonvard  and  may  be  grasped  be- 
tween the  forefingcT  in  the  vagina  and  the  fingers  of*  the  hand  on 
the  abdomen.     It  may  be  (enlarged  or  it  may  not,  and  tenderness 


HERNIA  OF  THE   ITERUS 


233 


on  pressure  and  induration  are  not  necessarily  present,  Shortcnetl 
irtf»ro-sacral  ligaincmt^  or  extraliganientous  aclhet^ions — ^these  latter 
rarely  pret^nt — limit  the  for^vard  exfur8ion  of  the  uterus  as  de- 
temiined  by  making  fonvard  traction  with  the  examining  hamb. 
Rigidity  of  the  tissues  at  the  angle  of  Hexion  is  det<*nnint^l  by 
manipulating  the  litems.  Downward  pressure  on  the  fnndus  by 
the  hand  on  the  abcioinen  moves  the  cervix  baekward,  and  up- 
ward pressure  on  the  fundus  by  the  finger  in  the  vagina  moves 
the  cervix  fonvard.  It  is  im|)OHsible  to  change  the  relation  of 
cervix  and  fumlus  to  eaeh  other  by  separating  two  fingers  placed 
between  them  in  the  vagina. 

As  a  rule  it  i^  not  necessary  to  pass  the  sound  in  order  to  verify 
the  diagnosis.  In  fat  women,  however,  with  thick  and  rigid 
abdominal  w^alls,  this  proeerlure  may  be  necessary.  Select  a  flex- 
ible Bcjimd  of  small  ealibT.  This  is  lictter  ami  safer  than  a  probe, 
the  tip  of  which  will  catch  in  pockets  of  the  lining  mucous  mem- 
brane. Bend  the  sound  so  that  it  rorres|K)nfls  to  the  bent  uterine 
canal  as  detcnnine<l  by  jialpation;  fix  the  cf»rvix  wuth  a  tenaculum 
and  make  gentle  traction,  thus  straightening  the  uterine  canal  as 
much  as  ]X)8sible.  Pass  the  sound  tentatively,  withdraw^  and 
rebt*nd,  until  the  tip  will  slip  through  the  internal  os.  Note  the 
[K>int  of  sensitiveness  in  the  uterine  canal,  if  any,  the  distance  of 
the  internal  os  from  the  external  os,  and  the  total  depth  of  the 
uterine  ca\ity.  Note  thus  thi*  relation  that  the  length  of  the 
cervical  canal  lx»ars  to  the  length  of  the  uterine  cavity  proi>er: 
also  consider  the  tightness  of  the  internal  os,  the  capacity  of  the 
uterine  cavity,  and  the  amount  and  character  of  the  dis<:harge. 
If  blood  follows  the  gentle  passing  of  the  sound  and  tenderness  is 
pn-H-tit,  one  may  diagnose  endometritis. 


(k  Hernia  of  the  Utkrus 

Hernia  of  the  uterus  through  the  inguinal  or  the  crural  canal  is 
a  rare  anomaly.  The  diagnosis  is  established  by  determining  the 
absence  of  the  uterus  from  its  nornial  situation  and  its  presence  in 
the  hernial  sac.  The  latter  is  a  most  diiticult  matter  and  most  of 
these  eases  have  b<x?n  operated  on  for  strangulate<l  hernia,  when 
the  diagnosis  was  made.  Congestion  or  tumefaction  of  the  hernial 
tumor  cont^ning  a  uterus  should  be  looked  for  at  the  time  of 


234  MALPOchITIOX.S  «»F  THE  ITERUS 

meastruation.  If  the  displace*!  utera<  becomes  pn^nant — as  it 
has  in  a  few  ca<es  reixirtc^nl  in  tin?  literature — the  tumor  becomes 
I>rogrr»ssively  larj^r-r  as  pregnancy  arlvances  and  the  symptoms  and 
signs  of  pregnancy  are  present. 


11.  ABNORMALITIES  OF  THE  AXIS  AND  FORM  OF  THE  UTERUS 

1.  Retroversion:  Ret roversio-flexion.  2.  Anteversion.  3.  Ante- 
flexion.    4.  Inversion.     5.  Torsion. 

1.  Retkoversiox 

Retroversion  is  that  abnormal  position  of  the  uterus  in  which 
th(»  h)ng  axis  of  the  organ  is  tilted  backward  to  or  beyond  the  long 
axis  of  the  vagina.  Retroflexion  signifies  the  bending  backwanl 
of  the  fundus  and  body  alone — a  flexing  of  the  utenis — and  there- 
fore a  change  only  in  fonn.  Retroversion  and  retroflexion  are 
commonly  associatcnl.  Th(»y  p^^s(»nt  similar  patholc^cal  condi- 
tions lyoih  as  regards  the  tissues  of  the  uterus  itself  and  the  sur- 
rounding organs;  th(nr  symptoms  are  the  same;  therefore,  they 
will  be  consid(T(»d  together. 

Retro versio-flezion. — This  is  one  of  the  commonest  uterine  mal- 
positions. As  has  \xvn  pointed  out  in  describing  the  mechanics 
of  prolapse,  in  order  that  the  ut(TUS  may  be  retro  verted  it  is  neces- 
sary for  the  cers'ix  to  leave*  its  normal  position — ^it  must  move 
forward — for  with  th(»  cervix  normally  situated  there  is  not  suffi- 
cient room  for  the  fundus  and  body  between  the  cervix  and  the 
unyi(*l(ling  sacrum.  RetrovcTsion,  then,  presupposes  a  stretching 
of  the  utero-sacral  ligaments.  Any  abnormality  tending  to  draw 
the  c(Tvix  forwanl  will  figure  as  a  cause  of  retroversion,  such  as  a 
bad  vesico-vaginal  fistula,  and  chronic  cystitis  with  contracted 
bladder,  thus  shortc^ning  the  anterior  wall  of  the  vagina.  This, 
fortunately,  is  an  unusual  condition.  Congenital  retroversion  is 
very  rare,  but  aftcT  the  menoi)ause  the  small  senile  uterus  is  found 
freciuently  in  this  position.  R(»laxation  of  the  uterine  ligaments 
is  the  chief  cause  of  retroversion.  AddcnJ  to  this  are  :  habitual 
dist(*ntion  of  the  l)la(l(ler:  chronic  distention  of  the  rectum;  in- 
creased weight  of  the  uterus;  retro-uterine  peritonitis;  adhesions 
jmlling  back  the  fundus;  chronic  cystitis,  with  contracted  bladder; 


RETROVEItSlON 


235 


i^umll  myoma  in  iU-  iitistcrinr  wall  of  the  furultis,  and  siuldt'o 
^i^aimng  or  a  violent  fall.  \\  Inn  once  the  axi.s  of  the  uterus  ha.s 
bet^n  tiirneil  Imckwanl  Wiry  act  of  (It^foration  or  straining  tnmLs 
to  jmsh  the  funikis  furtiier  tow  an  1  thr  sjwruni  l)ri*un.s(.'  the  thru^«t 
I  of  tin-  intra-al>tloiinnal  jm^ssnre  acts  on  the  anterior  rather  than 
on  the  posterior  fare  of  the  funchis.  It  Is  |>rnlml>lr  tliat  hackwaixl 
tilting  of  the  jielvis  on  the  s|>ine,  with  tlaitr-ning  of  the  foi-w^anl 
lumlrnr  eurv(*  of  the  ^imv,  due  U)  faulty  attitude  while  standing, 
Imssometliing  to  do  with  the  eausation  of  this  uterine  niali>osition, 


Fto.  92. — Retroversion  of  the  L'tenis, 

for  if  the  plane  of  the  peMc  inlet  becomes  more  nearly  horizontal 
antl  at  the*  same  time  the  inlet  is  not  protected  from  atxivc^  by  the 
forwunl  i)roj(>etion  of  the  lumbar  sj>iiH%  the  intra-alxlomijuil  pn»s- 
5»tire  b  tran^mittetl  more  directly  to  the  contents  of  the  pehis  and 
from  a  more  forward  tlireetion.  Tliis  pn*ssun*  from  the  front  is 
«ic«H*ntuate<l  by  tlie  contractions  of  the  alxluminal  muscles  in  strain- 
ing, thus  throwing  backward  large  masses  of  intestine  from  a  pro- 
tuberant abiomen.  which  is  often  jjresent,  in  these  cases, 

Thr  puerperiun),  with  its  lax^  non-involuterl  utrrinc  ligaments, 
ilicreast»d  weight  of  the  uterus  coujileil  witli  tlie  normal  retrover- 
l^n  from  the  patient's  recumbent  ^>osition,  \b  a  pecuHarly  favor- 
able time  for  the  nuiI(K>sition  to  Ix^gin.     It  is  not  easy  to  explain 
the  causation  of  retroversion  seen  so  conmionly  in  young  unmar- 


236  MALPOSITIONS  OF  THE  UTERUS 

ried  women.  Possibly  habitual  constipation  and  overdistention 
of  the  bladder  and  faulty  posture  may  have  something  to  do 
with  it.  The  symptoms  of  retroversio-flexion  are  not  distinctive 
and  there  may  ho  no  symi)toms.  If  present,  they  are:  a  sense  of 
weight  in  the  pehis  or  b(*aring-down  feeling,  irregularities  of  men- 
struation, uterine  catarrh,  constipation,  frequency  of  micturition, 
and  abortion  and  sterility.  In  the  case  of  retroflexion,  if  preg- 
nancy occurs  in  the  n^troflexed  fundus  there  is  less  likelihood  of 
spontan(»ous  reposition  than  in  retroversion,  and  therefore  abortion 
is  more  likely  to  occur.  The  bladder  and  rectal  symptoms  are 
apt  to  be  more  pronounced  in  retroflexion  than  in  retroversion 
because  in  the  former  there  is  more  dragging  on  the  neck  of  the 
bladder  and  a  sensitive  fundus  impinges  more  directly  upon  the 
lower  rectum.  The  degree  of  retroversion  is  a  variable  quantity. 
Formerly  it  was  customary  to  define  the  amount  of  tipping  of  the 
uterine  axis  with  great  exactness  and  the  retroversion  was  said  to 
be  in  the  first,  second,  or  third  degree,  according  as  it  w^as  tipped 
backward  so  that  its  long  axis  pointed,  respectively,  at  the  promon- 
tory of  the  sacrum,  in  the  axis  of  the  vagina,  or  it  exceeded  the 
last  amount  of  tilting.  Now  we  consider  the  okl  first  degree  to 
be  within  normal  limits.  It  is  well,  however,  to  preserve  these  dis- 
tinctions for  purposes  of  description. 

Diagnosis  of  Retroversio-flexion. — ^The  bimanual  touch  shows  the 
fundus  to  lx>  absent  from  its  normal  situation  and  the  cer\ix  in  the 
axis  of  the  vagina.  If  the  abdominal  walls  are  thin  and  relaxed 
it  is  possible  often  to  i)alpate  the  fundus  bimanually,  even  though 
it  is  n^troflexed.  In  less  favorable  cases  the  hand  on  the  abdomen 
determines  the  al)s(^nce  of  the  fiuidus  in  its  normal  position.  The 
fing(T  in  the  vagina  notes  a  sense  of  resistance  in  the  cul-<le-sac, 
or  in  th(*  case  of  retroflexion,  a  rounded  body  in  that  situation. 
Rectal  touch  is  of  great  assistance  in  the  diagnosis  of  both  retro- 
version and  retroflexion,  for  by  the  rectum  the  examiner's  finger 
can  reach  a  higher  point  in  the  pelvis  than  by  the  vagina.  One  of 
the  most  inipoi'tant  facts  to  determines  is  the  mobility  of  the  uterus; 
therefore  attempt  to  dislodge  it.  To  do  this,  make  an  upward  pres- 
sure on  th(^  fundus  by  the  left  forefing(T — protected  by  a  cot — ^in 
the  rectum  while  thc^  cervix  is  pushed  backward  by  the  right  fore- 
finger in  the  vagina,  th(^  i)atient  l)eing  in  Sims  position.  If  this 
is  unsuccessful,  hook  a  t(*naculum  into  the  cervix  and  make  down- 


RETROVERSION 


237 


ward  traction  while  the  rectal  finger  pushes  the  fiimliis  up.  If 
the  fiindu.s  ha^  been  displaet^l  from  the  hollow  of  the  saerum  by 
thest*  manipulations  the  tenaeuluiii  is  reniovt*(l  from  the  eenix,  the 
left  forefinger — the  eot  having  l>eeii  removed — is  transferivd  to 
the  vagina,  the  right  hand  is  passed  between  the  patient's  thiglis 
to  the  abdomen  and  the  uterus  rocked  into  place  b)'  the  bimanual 
touch.  The  knet^ehest  position  and  traction  on  the  eemx  with 
a  tenaculum  will  ohvii  accomplish  tln'  reiK)sition  of  an  olistiiiate 
rntrowrsion  or  an  incarcerated  pregnant  funtlus.  Sometimes  the 
dis]ilaee<l  fimdus  is  ht^ld  Ix-t ween  the  utero-sacral  ligaments.  Wlien 
the  uterus  is  raised  in  the  pehds  these  ligaments  are  relaxeii  and 
the  funtlus  may  lx»  piL^he^l  up  through  them.  In  some  eases,  es- 
j>ccially  in  virgins  with  tense,  well-developed  abdominal  walls,  noth- 
ing short  of  an  antithetic  will  permit  reposition  of  a  retroflcxeil 
utiTus  even  though  free  from  adhesions.  During  the  manipu- 
lation the  physician  gains  a  knowledge,  through  his  sense  of  touch, 
of  the  other  (x-lvic  organs.  He  detects  sjilpingitis  or  thickenings 
denoting  adhesions.  He  notes  points  of  tenderness,  and  these  warn 
him  against  \ngorous  attempts  at  rej>osition.  When  the  Peaslce 
rigid  uterine  sound  was  first  inventetl  it  was  customai-y  for  the 
prai'titioner  of  that  flay  to  pass  it  into  the  uterine  cavity  and 
forcibly  pry  the  uterus  into  placf,  and  the  trauma,  together  with 
the  lamk  of  asepsis  which  iirevaikHl  at  that  time,  produce*!  most 
dinaiStrouB  result^^  in  the  form  at  twnte  peKic  inflammation,  salpin- 
gitis, or  even  jM*lvie  alwess. 

SupjKPS*^  th<*  fundus  has  bf»en  frf*e<l  from  its  abnonnal  position, 
the  next  procedun^  is  to  hold  the  cer\ix  backward  while  you  resell 
for  the  fundus  with  the  fingers  of  the  right  ham!  on  the  alKlomen, 
working  tliem  b-hind  it  by  gradual  ami  re|_M^ated  pressure  as  the 
imtient  takers  d(M^p  inspirations.  Backward  pi*(\ssuR*  on  the  cervix 
and  fonvard  rocking  on  the  fundus  restort*  the  uterus  to  its  nornud 
pofidtion.  The  Irimanual  touch  practiced  in  the  Sims  j^sition  is 
meet  useful  for  this  pnx't*thin*.  Always  1m*  sure  that  the  bladd*'r 
\h  i^mpty  before  lieginning  the  mam'pulations.  If  the  uterus  comes 
up  do  the  ovaries  alsti  assume  a  normal  jxjsition?  Note  their  size 
as  well  as  thpu*  moliility.  In  exceptional  cas(»s  the  aseptic  sound 
may  be  passixl  to  confirm  a  tliagiiosis,  esi>ecially  in  castas  of  retn> 
flexion.  Here  it  is  generally  necessary  to  pass  a  sound  to  differ- 
entiate from  a  fibroid  in  the  [>osteiior  uterine  wall.     It  is  necessary 


238  MALPCXSITIONS  OF  THE  UTERUS 

to  exclude  ail  inflainniatory  mass  or  abscess  ix)sterior  to  the  uterus, 
and  this  is  done  by  noting  the  shajxi  and  situation  of  the  inflamma- 
toiy  mass.  Recto-abdominal  touch  shows  it  to  be  situated  in  the 
recto- vaginal  s(^ptum,  and  it  is  generally  a  little  to  one  side  or  to 
the  other,  and  not,  like  the  retroflexcnJ  fundus,  directly  in  the 
median  Hne.  A  scybalous  mass  in  the  rectum  is  detected  by 
rectal  touch.  In  doubtful  cases  cleanse  the  rectum  by  a  suds 
encnna. 

In  diagnosing  retroversio-flexion  it  is  often  not  advisable  to  make 
a  comi)lete  diagnosis  at  one  sitting.  Sometimes  the  best  plan  is 
to  i)ack  the  vagina  with  cotton  tampons,  cleanse  the  bowel  by  a 
cathartic,  and  see  the  patient  again  after  a  lapse  of  two  days, 
when  it  will  \x}  found  that  a  retroveileKl  uterus  has  been  replacc^l. 
In  other  cases  the*  j)resence  of  pehic  inflammation  or  salpingitis  in 
a  chronic  stage  makers  replacement  inadvisable.  In  such  cases 
tn^atnu^nt  with  glycerin  tampons,  vaginal  suppositories,  and 
douches  is  to  Ix^  employed  until  the  subsidence  of  the  inflamma- 
tion. After  a  second  or  third  examination  the  physician  will  have 
a  l.x»tt(M'  id(^a  as  to  th(»  pathological  condition  of  the  pelvic  organs 
and  will  Ix'  in  a  {position  to  advise,  if  necessary,  etherization  for  a 
compl(»t(»  diagnosis.  Progressing  too  fa^st  or  too  vigorously  has 
often  done  great  damage  by  lighting  up  dormant  inflammation, 
rupturing  adhesions,  and  causing  hemorrhage,  or  scjucezing  jjus 
from  inflanuHl  tulx's. 

2.    AXTKVKHSION 

This  is  of  Hltlc*  importance  clinically  and  is  to  Ix)  classed  with 
lateroposition  or  lat(T()V(Msion.  Sometimes  freciuency  of  micturi- 
tion is  found  in  cjises  of  antevei-sion :  in  this  case  it  is  due,  appar- 
ently, to  traction  mmh*  on  the  neck  of  the  bladder  by  the  exagger- 
ated posterior  position  of  the  cervix,  for  the  symptom  is  done 
away  with  by  elevating  the  fundus  with  a  Hodge  or  Gehnmg 
p(\^sary.  Tlu^  diagnosis  is  established  by  the  bimanual  touch, 
the  fundus  Ix'ing  found  w(^ll  down  Ix'hind  the  symphysis  pubis 
and  the  ci^rsix  high  in  the  pelvis.  The  axis  of  the  uterus  coin- 
(»id(\^  very  nearly  with  the  axis  of  the  vagina  in  extreme  degrees 
of  antevei-sion. 


240  MALPOSITIONS  OF  THE  UTERUS 

3.  Axtp:flexion 

Anteflexion  has  bc»en  describcHl  at  length  under  Rctropo^tion 
with  Ant(*flexion.  It  is  to  be  understood  that  this  malformation 
of  the  uterus  does  occur  without  the  posterior  malposition.  What 
has  been  said  of  the  combined  disorder  applies  equally  to  the 
flexion  alone. 

4.  Inversion 

Inversion  of  the  uterus  is  a  partial  or  complete  turning  of  the 
organ  inside  out.  It  is  of  three  sorts:  (1)  acute  puerperal  inver- 
sion, (2)  chronic  puerperal  inversion,  and  (3)  inversion  caused  by 
uterine  tumors.  The  first  sort  concerns  the  obstetrician.  The 
second  is  th(^  more  usual  of  the  remaining  two  forms  that  are  seen 
by  the  gynecologist. 

Pu(»ri)(Tal  inversion  is  due  to  relaxation  of  the  uterine  muscles 
at  the  time  of  the  delivery  of  the  placenta.  Coughing  or  sneezing 
may  invert  a  relaxed  uterus;  too  nuich  traction  on  the  cord  and 
an  adherent  i)lacenta  are  the  direct  causes  in  some  cases.  The 
uninvertal  part  of  th(»  ut(Tine  wall  may  s(»ize  the  inverted  part 
so  that  th(>  uterus  looks  like  th(^  lx)ttom  of  a  wine  bottle,  and  the 
contraction  of  the*  unrelaxed  portion  may  continue  to  push  the 
fundus  downward  until  th(»  uterus  is  completely  inverted.  The 
process  may  start  in  the  l()W(»r  utcTine  segment,  which  is  inverted 
first,  and  is  followt^d  by  tlu^  fundus.  The  tul:H\s  follow  necessarily 
into  tli(^  cup  of  the*  invi^-ted  fundus  and  sometimes  also  loops  of 
int(\stin(^s,  ])ut  tlies(»  structures  are  seldom  adherent.  The  evert<Ml 
nuicosa  of  the  uterine  cavity  is  dark  red  and  bleeds  easily,  and  in 
cases  of  Icjng  standing  inversion  it  shows  regions  of  ecchymosis 
and  ulc(»ration.  Cases  have  l^ec^n  reported  where  there  were  ad- 
hesions l)(*tween  thc^  partially  invc^rted  fundus  and  the  cer\ix. 
If  invt^rsion  is  due  to  downward  traction  on  the  uterine  wall  by  a 
submucous  fibroid  th(*rc  is  apt  to  he  present  a  foul  uterine  dis- 
charge, for  tlu^  fibroid  is  generally  in  a  state  of  necrosis.  The 
usual  sym[)t()ms  of  cl ironic  invei'sion  an?:  jK^lvic  pain,  hemorrhage, 
leucorrh(»:i,  fn^ciuency  of  mi(;turition  and  dysuria,  and  difficulty  in 
walking  and  standing. 

Diagnosis  of  Inversion. — In  favorabk^  cases  where  the  abdominal 
walls  arc  relaxed  and  the  patient  is  not  fat,  the  bimanual  touch  will 


242  MALPOSITIONS  OF  THE  UTERUS 

show  the  absence  of  the  uterus  in  its  customary  situation.  Rectal 
touch  is  of  great  use*,  also  the  recto-abdominal  touch,  and  the 
rectal  touch  with  a  sound  in  the  bladder.  In  extremely  favorable 
cases  the  depression  of  the  inverted  cup  may  be  made  out  by  the 
abdominal  hand.  By  vagina  the  partial  or  completely  invert<Hl 
uterus  is  felt  and  seen,  and  occasionally  the  orifices  of  the  Fallopian 
tubes  can  be  demonstrat(*d  in  the  inverted  fundus.  The  ring  of 
the  cervix  can  b(^  felt  by  th(»  finger  swept  about  the  inverted  fundus. 
The  difficult  point  in  diagnosis  is  to  differentiate  complete  inver- 
sion from  submucous  myoma. 

By  reference  to  the  figures  on  page  241,  it  will  be  seen  that  a 
myoma  may  si)ring  from  tlu^  fumlus,  body,  or  cervix.  It  may  he 
sessile,  or  have  a  short  [XMlicle  or  a  long  one.  Fig.  100  shows 
an  unusual  condition:  a  jxHlunculated  subperitoneal  fibroid  at- 
tached to  the  cervical  region — the  uterus  being  in  a  state  of  com- 
plete inversion — and  the  fibroid  tumor  presents  to  the  examiner's 
touch  the  size  and  shape  of  a  uterus  in  a  normal  situation.  Li 
such  a  case  it  would  be  extremely  difficult  to  tell  the  uterus  from 
the  tumor.  Detection  of  the  orifices  of  the  Fallopian  tubes  and 
also  the  ring  of  the  cervix  would  Ixi  the  distinguishing  features. 
Complete  prolapse  can  be  difi'erentiated  from  an  inversion  by 
finding  in  the  pr()la[)se  the  ext(M*nal  os  uteri;  the  extruded  mass 
is  widc^r  above  and  narrower  Ix^low;  and  the  vagina  is  everted  to  a 
greater  or  less  degree,  as  sliown  by  iho.  fact  that  the  point  of  a 
sound  introduced  into  the  bladdc^r  can  be  felt  in  the  hernia.  In 
the  case  of  inversion,  on  the  other  hand,  there  is  no  external  os, 
the  orific(\s  of  tlu^  tubes  may  \yo  seen,  and  a  sound  in  the  bladder 
goes  ui)ward,  except  vcTy  rarely  when  the  vagina  also  is  inverted. 

Differential  Diagnosis  of  Inversion. — The  following  is  a  tabulated 
statement  of  the  (liff(»rential  diagnosis  between  complete  inversion 
and  pedunculated  fibi'oid  in  th(^  vagina,  and  incomplete  inversion 
and  intra-uterine  subnuicous  fibroid. 

Complete  Inversion.  Pedunculated  Fibroid  in  Vagina. 

1.  Sweeping  finger  and  sound  alx)ut  1.  Tumor  is  atUiched  at  one  point  by 
tumor  shows  it  to  have  no  point  of  at-  a  broader  or  narrower  attachment, 
taehment.  Verify  location  and  size  of  attachment 

by  the  sound. 

2.  Sound  will  enter  ring  of  cervix  but  2.  Sound  goes  to  fundus  a  distance 
a  short  distance.                                            of  2}  inches  (six  centimeters),  at  least. 


T0R8I0N 


243 


ComidHe  Inverrion. 

3»  Uterus  absc?nt  in  abdomen  ti>  bi- 
manual C'xamtruAtioii. 

4.  Ifrmiu  masH  is  symnietricaJ,  bir- 
ger  bi'low  and  imrrower  alM>ve. 

5*  Orifict'a  of  the  Fallopian  tu1>es  arc 

Ioft^i  dcmoii!Jtrabic. 
Ineamplde  Jnver&imt. 
1.  Uterine  cavity  in  shallow  as  meas- 
ured by  sound. 
2-  Cup-sbapcd  depression  in  uterus 
fell  bimanuiilly. 
:i.  Symptoms  date  from  part urit  ion, 
CO 


Pcttuncultdcti  Ftbroid  in  Vnginat 

(coniinued) 
'A.   I'lLTus  i>n.*8init  in  nbiomen. 

4.  Mass  may  be  asymmetrical. 

,'i.  No  orifices  of  (he  Fallopian  tubes. 

Intra-Uterint  SuhmumttM  Fibnmt, 
K  Cavity  deep. 

1\  No  eup-ehaperj  duprcMsion, 

3.  Byrnptoins  do  not  date  from  par- 
turition. 


a  ToRsio.v  OF  THE  IItebus 


Torsion,  or  twisting  of  the  uterus  on  its  own  long  axis,  may  l>e 
complete  or  it  may  Ix*  pnrtial.  In  thi*  ftirini*r  thi*  entire  uterus  is 
twiste*]  to  one  side  or  the  other,  generally  not  more  than  half  a 
H  turn,  as  in  the  east.*.':^  of  anteflexion  or  retroflexion  where  one 
I  utero-saeral  ligament  is  shortemnl.  In  the  case  of  tumors  growing 
from  one  side  of  the  pc*lvis,  however,  the  uterus  may  be  twisteil 
aeverat  times  on  its  own  axis.     Torsion  of  the  uterus  oecun^ing  with 

I  a  fibroid  of  subsemus  evolution,  or  an  ovarian  tumor  haWng  a 
short  pedicle,  is  generally  partial.  The  cervix  uteri,  bnng  steadied 
bj"  the  insc^rtions  of  th(5  broad  ligaments,  is  not  so  ajit  to  parliei- 
mte  in  the  twist  and  ttie  uterus  is  twsted  on  itself,  the  fimdus 
iiid  botly  alone  taking  part  in  the  twist. 
Torsion  is  especially  ajit  to  be  foun<l  in  the  case  of  double  uterus 
m  uterus  bieornis. 
The  diagnosis  Is  made  by  determining  l*y  the  bimanual  touch 
the  j)Osition  of  the?  ovaritis  and  also  tht*  situation  atul  direction  of 
the  tran^'crse  axis  of  the  fundus  with  reference  to  the  cer\ix.  In 
the  event  of  comjileti'  torsion  of  the  uterus  the  transverse  axis  uf 
ihe  external  os  niay  l)e  He<*n  tlirough  the  vaginal  s]X)culum  tf)  Ik* 
turned  away  from  the  normal. 


CHAPTER  XV 

THE   DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

Definition,  p.  244.  Patholog\',  p.  244.  Classification,  p.  245.  Situation, 
p.  248.  Frequency,  p.  248.  £tiolog}\  p.  250.  Course  and  Develop- 
ment, p.  251.  Degenerations,  p.  252.  Complications,  p.  255.  Effect  on 
neighboring  organs,  f).  257.  Effect  on  distant  organs,  and  on  the  system, 
p.  258.  Relation  of  fibroid  tumors  to  heart  disease,  p.  259.  Dangerous 
to  life,  p.  260.  SMiiptoms,  p.  260.  Symptoms  of  adenomyoma,  p.  262. 
Diagnosis  and  differential  diagnosis,  p.  262.  Subserous  fibroids,  p.  262. 
Intraligamentous  fibroids,  p.  263.  Interstitial  fibroids,  p.  263.  Submucous 
fibroids,  p.  264. 

DEFINITION 

Fibroid  tumor,  also  called  myoma,  fibromyoma  or  fibroma  of  the 
uterus,  is  a  nodular  growth  developing  from  some  portion  of  the 
uterus,  usually,  but  not  always,  above  the  cervix,  varying  in  size 
from  a  minut(^  si)eck  to  a  mass  or  masses  filling  the  pelvic  and 
abdominal  cavities. 

PATHOLOGY 

The  largest  fibroid  which  I  have  found  recorded  was  one  re- 
moved at  autopsy  from  a  single  woman  fifty-three  years  of  age 
by  S.  H.  Hunt  of  Long  Branch,  N.  J.  {Amer.  Jour,  Obstet., 
1888,  XXI.,  J).  62.)  It  weighed  one  hundred  and  forty  pounds 
and  the  cadaver  after  the  removal  of  the  tumor  weighed  ninety- 
fiv(;  pounds. 

Tlu^  tumors  are  gc^nerally  round  in  shaj^e,  with  smooth  surface, 
but  may  bo  i)(*ar-shaped,  kidney-shaped,  mulberry-shaped;  may 
b(^  molds  of  the  pelvic  cavity,  or,  verj'  rarely,  may  resemble  a 
fetus.  Th(*y  are  singh^  or  multiple,  as  many  as  one  hundred  and 
fifty  tumors  having  Ixm'u  found  in  the  utenis  by  Bland-Sutton. 
{Bvit.  Med.  Jour.,  April  0,  1001.)  They  are  of  a  hard  consistence, 
though  a  ])red()nnnance  of  nniscular  tissue  in  their  structure,  or 
degenerative  changes,  may  render  them  softer.    They  are  classed 

244 


CLASSIFICATION 


245 


I 

I 
I 

I 


as  lx»nign  tumors  l>ecause  they  do  not  ^'eat  up*'  the  BuiToundiii^ 
tissues  by  extending  into  their  suh<tance,  and  they  do  not  cause 
de^tnietion  l\v  nieta.stases.  They  are  conipuscd  of  the  same  tissues 
as  the  uterus,  nanM*ly,  unstri{>etl  niuisele  fil>ers  and  connective 
tissue.  On  section  a  fibroiil  tumor  is  of  a  glistening  white,  or 
whitish-yellow  color  and  is  5f*en  to  \w  made  up  of  a  disorderly 
intertwining  of  muscular  and  ronneetive-tissue  filxTs.  In  the  larger 
masses,  however,  thes4*  are  grouiHMl  iti  more  or  less  well-defined 
whorlB  (see  Fig.  lt)6)  winch  somewhat  resemble  knots  in  a  piece 
of  wood.  Betwt»ini  the  groups  of  filx^rs  run  ailerieSy  veins,  and 
lymph  channels  derived  from  the  normal  vessels  of  the  uterus, 
ramifying  at  first  beneath  the  capsule  of  the  tumor  and  then 
plunging  dirc^ctly  into  its  interior.  As  a  rule  the,se  tumors  are 
poorly  nourished  because  they  derive  their  blooil  from  the  sur- 
rounding constrictefl  uterine  tissue.  Occasionally  they  are  sup- 
plied by  large  vessels  through  adhesions  to  surrounding  organs. 


CLASSIFICATION 


Fibroid  tumors  may  be  classified  according  to  their  situation  \^ith 
fen^nce  to  the  uterus.     They  are — 

1.  Subserous, 
(a)  Intraligamentous. 
(6)  Tumors  of  the  cervix. 

2.  Interstitial. 

3.  Submucous. 
They  are  deseribxl  furthfT  by  defining  their  number  and  size, 

id  by  noting  any  special  kinil,  as  ailenomyoma.  For  instance, 
in  Fig.  102  we  see  a  spei^iinen  of  a  multiple  fibroid  uterus:  an 
interstitial  fibroid  of  the  anterior  uteiine  wall,  a  subserous  fibroid 
springing  from  the  fundus  uteri,  ainl  an  inteivtitial  tumor  of  the 
posterior  wall.  All  fibroids  originate  in  the  uterine  muscle,  there- 
fore all  are  interstitial  in  the  beginning.  If  tlje  tumor  develops  in 
the  outer  wall  of  the  utenis  anri  grows  from  the  uterus  under  the 
peritoneum,  it  is  calletl  an  adenomyoma. 

Adenomyoma  is  a  special  variety  of  myoma  characterized  by  the 
.•l^rcsence  of  glands  similar  to  those  found  in  the  uterine  mucosa. 
Thomas?   S,  Cullen  (*' Adenomyoma  of  the  Utenis,"  1908)  found 


246 


DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  ITTERUS 


7^  cases  of  iKlciioinyoma  among  12S,'i  easels  of  niyoina  oxamineil 
niicroscopically  in  tlu*  Johns  IIoj)kins  Ilosi)ital  Surgical- Patho- 
logical LalK)ratory  during  thii-toen  years,  or  5.7  per  c(»nt  of  all 
fibroids.  These  tumors  are  diffuse  and  may  or  may  not  be  definitely 
encai)sulat(Hl. 

1.  Subserous  Fibroid  Tumor.— Such  tumors  have  the  greater  part 
of  their  perii)hery  outside  the  ut(Tine  wall  and  have  no  considerable 
covering  of  uterine  tissue.     (See  Fig.  102,   upper  tumor.)     The 


I'ic.  102.— Multiple  Fibroids,  One  Subserous  and  T\v'o  Interstitial.     (Winter.) 

greater  tlie  size  of  the  sul)ser()us  tumor  the  more  it  is  separatc^l 
from  th(^  ut(M-ns,  as  a  rule.  It  may  l)e  relatively  small  or  large. 
If,  instead  of  (level()])ing  under  th(^  s(*rosa,  the  tumor  separates  the 
folds  of  the  broad  liganu^nt  and  distorts  th(^  viscera  to  a  greater  or 
less  degree,  it  is  called  an 

(a)  Intraligamentous  Fibroid  Tumor.  (See  Fig.  105.) — These 
tumors  have  the  greater  ])art  of  their  circumference  outside  the 
ut(Tus  and  are  not  covered  l)y  uterine  tissue.  Noble  (" Gjmecolog}' 
and  Abdominal  Surgery,"  II.  A.  K(^lly  and  (\  P.  Noble,  1907,  p.  669) 


CLASS  IFTCATION 


247 


fouiif!  this  form  of  tumor  in  3,5  |x*r  vimi  of  the  2,274  L'ases  of  fibroiil 
tumor  he  studied.    The  same  rharat*t(Tii!ftics  belong  to 

(/;)  TumoFfi  niiich  orlijinfile  in  the  hiver  po.steriiyr  sctpnctit  of  (he 
ute)*iui  and  grow  into  the  cervix  mu\  then  into  the  j»osterior  jielvis, 
or  tliase  rare*  tunioi*R  wliieh  orifj:inate  in  the  cvvxix  itself  anil  de- 
velop away  from  the  uteni.s.  i^cv  Fig,  108,)  The  cervix,  to 
bt*  sure,  has  no  covering  of  peritoneum.  A.s  the  tumor  increai>i\s 
in  size  and  tiugs  in  the  pelvis  it  puishes  the  peritoneum  before  it. 
Therefore^  this  class  of  tmiiors  may  \je  iJicluded  among  the  8ub- 


'/ 


I 


Fig*    ll)3> — Large   Multinodular   8iibiifritom«al    rH^roul   with    Thiti    Abdominal 
\V:ilb.     8wn  in  ProfiJe,     (Kelly J 

US,     In  sul>siTou.s  fibroids  llic  utrrine  cavity  i«  altered  little  if 
all  in  length  or  shape. 

2,  Interstitial  (intramural,  intraparietal )  fibroid  tumors  are  those 
which  ai'e  situated  in  the  wall  of  the  uterus  and  are  siu'rounded 
by  a  covering  of  uterine  musculature.  (See  Figs.  102  and  104,) 
They  may  or  they  may  not  alter  the  contour  of  the  uteruj^.  Tlic 
uterine  cavity  h  almost  always  lengthened,  ami  it  may  Ix*  broad- 
eni^I  anti  made  asynimetrical  in  shafx'  by  this  fonn  of  tumor, 

3,  Submucous  Fibroid  Timiors,^The.sc*  are  the  tumors  which  dc^ 
velop  into  the  uterine  cavity  imd  are  covered  with  mucous  mem- 
brane and  with  little,  if  any,  of  the  uterine  miLsculatun*.  (S«X5 
Fi^,  104  and  106.)  Of  ail  the  three  varieties  these  cause  the 
great e;4t  changes  in  tlie  form   of   tht*   uterine  cavity.    These   are 


248        DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 


the  bleeding  fibroids.  The  pressure  exerted  by  the  tumor  on 
the  nervous  mechanism  of  the  uterus  set^  up  reflex  uterine  con- 
tractions producing  a  gradual  deliver}^   of  the  tumor.     At   first 

the  tumor  becomes  pedunculated;  then 
the  pedicle  is  elongated  until  the  inter- 
nal OS  has  been  dilated.  Finally,  in 
favorable  cases,  the  tumor  is  delivered. 
More  often  necrosis  of  the  tumor  sets 
in  lx»fore  the  delivery  is  accomplished, 
and  we  have  a  Sloughing  Fibroid. 

A  pedunculated  submucous  fibroid, 
if  of  small  size,  is  caUed  a  fibroid 
polyp  (see  Fig.  107),  and  is  to  be  dis- 
tinguished from  a  mucous  polyp,  one  of 
the  manifestations  of  glandular  endo- 
metritis. In  all  forms  of  fibroids,  more 
especially  in  the  submucous  and  the  in- 
terstitial, the  mucous  membrane  of  the 
corpus  uteri  may  show  evidences  of 
glandular  and  interstitial  endometritis. 
Kelly  and  CuUen  ("Myomata  of  the 
Uterus")  state  that  the  mucous  membrane  of  the  uterine  ca\ity 
is  generally  noniial,  but  that  cervical  endometritis  is  relatively 
frequent  when  a  sloughing  submucous  myoma  exists,  otherwise 
it  is  rare  even  if  there  Ix^  present  evidences  of  an  old  inflamma- 
tory process  in  the  ovaries  and  tubes.  Therefore  they  point  out 
that  the  siu-geon  may  open  the  uterine  cavity  with  impunity  in 
the  absence  of  vaginal  discharge  and  signs  of  tubal  disease. 


Fia.    104.— Interstitial    and 
Submucous  Fibroids. 


SITUATION 

Fibroid  tumoi-s  always  originate  in  the  substance  of  the  ut^^rine 
wall.  They  almost  always  develop  in  the  body  rather  than  in 
the  neck  of  the  uterus,  and  they  are  more  commonly  found  in  the 
posterior  than  in  the  anterior  or  lateral  walls. 


FREQUENCY 

Fibroid  tumors  are  the  most  prevalent  of  all  neoplasms  affecting 
the   uterus.    As   regards   their   frequency   among   women,  ma«^ 


FREQUENCY 


249 


ithors  <juote  Bayle  (S,  H.  Bayle,  **  Diet."  on  60  vol.,  Parin,  1813,  L 
\1I.,  p.  73)  who  i^itiivtl  as  long  ago  as  1813  that  20  jkt  cent  of  all 
women  over  thirty- five  years  of  ago  have  fibroids;  but  as  other 
authors  have  arrived  at  different  results  (Klolj,  for  instance,  assert- 
ing that  40  per  cent  of  the  uteri  of  women  who  die  after  the  fiftieth 
yt*ar  contain  fibroid  tumors),  and  as  Bayle's  opinion  luu?  not  been 
confirmed,  we  may  state  that  the  exact  frecjuency  of  tlii'  t iiniurs  is 
yet  to  be  d(»termine*i.  They  are  met  with  mostly  dm'ing  the  period 
of  sexual  maturity,  between  the  ages  of  thirty  and  fifty  years,  being 
rare  before  twenty  and  after  fifty-five.  Gusserow,  out  of  919  cases  of 
fibroids,  found  only  15  under  twenty  years  of  age  and  ordy  17  over 


Left  ovary •^ 


InTraligCLmefjtbus  1 1 


fOfOnf 


\ 


TX] 


I 


Fio.  105. — Diagmni  Showing  an  Intraligamentous  Fibroid. 

ty  years  of  age.  The  highest  {percentage,  38,8,  was  between  the 
^t*8  of  thirty  and  forty,  and  the  next  highest,  36J,  was  between 
forty  and  fifty.  Fibroids  are  undoubtedly  wry  fri^iuent  in  the 
ne^ro  race.  The  autopsy  statistics  of  the  Jolins  Hopkins  Hospital 
show,  acconiing  to  K*'lly  ami  Cullen  C'Myomata  of  the  Uterus/' 
1909),  that  out  of  742  autopsies  on  white  and  black  w^omen,  over 
twenty  years  of  age,  20  ]wr  cent  had  fd>roifls  in  their  uteri,  and  of 
thcjse,  33.7  per  cent  of  the  black  w^omen  hatl  uterine  myomata,  and 
10  [XT  cent  of  the  white  women  were  affected  in  this  w'ay.  It  is 
not  yet  determinetl  whcHher  fibroids  are  more  common  among  the 


250 


DIAGNaSlS  OF  FIBROID  TITMORS  OF  THE  UTERUS 


single  than  the  inamcMl.  Bayl(»  and  other  authors  thought  that 
they  wen^,  while  Gussctow,  Dupuytren,  West,  and  others,  hold  tliat 
th(»y  are  not. 

ETIOLOGY 

Th(»  causation  of  these  tumors  is  even  now  unknown,  although 
the  probknn  has  been  studitnJ  assiduously  by  many  not^  invei^ti- 


Fig.    lOG. — Large    Submucous    Fibroid    showing    Distortion    of    the    Uterine 

Cavity.     (Kelly.) 


gators  (luring  the  last  fifty  years,  and  many  hypotheses  have  been 
advanced,  but  so  far  none  lias  been  [) roved  correct.  An  ingenious 
theory  is  that  advances!  by  A.  Claisse  (Th^se  de  Paris,  1900).  He 
thinks  they  are  due  to  infection  of  the  uterine  mucosa;  subacute 
inflammatory  lesions  of  the  mucosa,  especially  about  the  little 
blood-vessels  of  the  muscular  wall,  causing  proliferation  of  round 
cells,  which  are  transformed  into  fibrous  tissue.  Heredity  has  been 
supposed  to  play  a  pai1  in  the  causation  of  fibroids;  Hofmeier, 
Veit,  KIeinw;icht(M-,  and  othei*s  considering  it  a  predisposing  cause. 
It  is  doubtful  wh(»tli(T  this  assumption  is  w(*ll  founded,  however, 
and  we  nmst  regard  the  occurrence  of  fibroid  tumors  in  members 


rorR>?E  AST)  DEVELOrMENT 


251 


of  the  Hanie  fninily^a  not  uiicouiiuon  hiip|M"iiiii)j; — as  eoinridciu'cs 
rnthiT  than  exaiiipk^s  oi  hen^dity. 

Sextial  irritation,  siicli  as  mast iniiat ion  oj'  alTMornifil  sexual 
practicet^,  has  1)cqu  assigmMl  as  a  c*ausi*  of  niyonm  by  \'v\t.  \\  liili* 
the  chronic  congpj^tjon  which  is  due  to  inn  hie  irritation  of  thf 
genital  organs  may  a^^isi  the  growlh  of  a  fihniid,  it  is  difFicnlt  to 
sei*  how  it  couM  originate  one.  It  is  ijrohiilJt'  that  many  lil>roitl.s 
of  congenital  origin,  i>erhaps  due  to  a  fetal  misplaeement  of 
tissue  accortling  to  Cohnheim*s  th«*ory,  but,  as  ah'eady  statcni, 
this  ha*^  not  l)een  proved.  The  tumors  do  not  attain  any  con- 
siderable size  until  the  lat(^  ehild-lji'aring  [K^ricH^  therefore  age 
must  be  considered  a  facttjr  in  tlit*  etioh»g)'. 


COURSE   AND   DEVELOPMENT 

development  of  a  fibmid  is  a  slow  affair,  g(*nerally  a  matter 
years.  11.  A.  Kelly  has  eited  a  eas<^  whieh  wa*^  under  mediral 
olisi*rvation  for  twenty-five  y(*ars  lH*fort»  opt'rati*»n  and  two  velars 
after.  «/* Operative  Gynecology/*  H»()7,  \ Dl.  II.,  p.  347.)  A  large 
interstitial  tumor,  with  a  uterine  cavity  measuring  eight  or  nine 
iiches,  became  larger  and  sul>peritoneal  and  perluneulatiil  so  tliat 
operatitju  it  wa^  found  atla(*hed  to  a  sjuail  uterus  by  a  [M'diele  1 
centimeter  long  and  3  centimeters  broad.     It  weiglied  59  pounds. 

I  have  sjx)ken  of  the  direction  of  the  growth  in  ileseribing  the 
differt*nt  kinds  of  tumors.  Upon  the  course  taken  by  the  tumor 
ill  itii  growth  deix^nds  often  its  subsequent  fate.  For  instance, 
if  it  gnjws  subsiTous  it  may  Ix^come  pedunculated  and  in  time 
may  be  separated  entirely  from  the  uterus^  receiving  its  nourish- 
ment through  mlhesions  to  surrounding  structures.  Such  easels 
are  rare,  but  are  met  with  occasionally.  If,  on  the  other  hand,  the 
tumor  grows  toward  tlie  uterine  cavity,  it  is  a|)t  to  I)e  extruiled 
through  the  external  os.  In  either  cjise  the  blood  supply  to  the 
tumor  is  interfen^il  with  ami  there  is  a  tendency  to  necrosis  and 
ck»generative  changes.  If  the  tun»or  remains  in  the  sutetanee  of 
the  uterus,  as  in  the  ca.*^^  of  an  int<'i>?titial  fibroid,  its  nourishment  is 
tabHshed  on  a  surer  footing.  It  is  possible  for  all  tumors,  ami 
small  tumors  especially,  to  remain  in  a  r|uiescent  state  for  an 
Tndefinite  i>eriod.  Bland-Sutton  (**  Tumours  Innocent  and  Malig- 
nant/' -1th  Edititju,  19(10.  p.  1S7)  calls  attention  to  the  latmt  seedltmj 


252        DUGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

fibroids  J  in  regard  to  which  ho  says:  "If  a  number  of  uteri  be  ex- 
amined from  women  Ix^twei^n  the  twenty-fifth  and  fiftieth  years  by 
the  simple  means  of  sectioning  them  with  a  knife,  in  a  large  propor- 
tion of  these  uteri  a  number  of  small  rounded  fibroids,  resembling 
knots  in  wood,  will  appear,  their  whiteness  being  in  strong  contrast 
with  the  redness  of  the  surrounding  muscle  tissue.  These  discrete 
bodies,  in  many  instances  no  larger  than  mustard  seeds,  are  in 
histologic   structure   identical   with   the   fully   grown   tumours." 


Fig.  107. — Pedunculated   Fibroid   Originating  in   the   Cervix  that  has  been 
Expelled  into  the  Vagina.     (After  Auvad.) 

When  removing  fibroids  by  operation  one  can  never  be  sure  that 
all  tumors  have  been  removed;  therefore,  a  patient  can  not  be 
assured  that  the  fibroids  will  not  grow.  On  the  other  hand, 
tumors  may  increase  rapidly  in  size.  Soft  tumors  grow  faster 
than  hard  ones,  as  a  rule.  Fibroid  tumors  grow  during  pregnancy 
and  diminish  in  size  markedly  after  delivery.  They  increase  in 
size  just  before  c^ach  menstrual  period  and  diminish  after  the  flow 
has  ceased.  In  many  instances  they  lessen  in  size  after  the  meno- 
pause, but  not  always.  All  these  facts  nmst  Ix^  kept  in  mind  when 
examining  a  patient  at  diff(»rent  times  to  determine  the  relative 
bulk  of  a  tumor. 

DEGENERATIONS 

There  arc  certain  alterations  of  structure  occurring  in  fibroids, 
the  causes  of  which  we  do  not  know,  except  that  sometimes  they 
can  be  explained  by  thc^  presence  of  arteriosclerosis  and  a  diminished 
blood  supply.  Degenerations  in  fibroids  are  observed  frequently 
following  pregnancy.    An  increased  formation  of  fibrous  and  hya- 


DEGENERATIONS 


253 


line  tissue  occurs  in  practically  all  myumata  and,  when  the  process 
is  extensive,  necrosis  of  the  center  occiu^,  with  a  resulting  cyst 
cavity  with  walls  of  irregular  outline. 

Softening  of  a  fibroid  tumor  may  lx»  duo  to  several  causes. 
Among  iheni  we  may  enumerate  hyaline,  colloid,  and  fatty  de- 
generation. 

Hyaline  degeneration  was  noted  in  3,1  per  cent  of  2,274  cases 
of  fibroid  tumors  collirted  by  Noble  from  the  literature  C*Gj7iecol- 
ogy  and  Abdominal  Sui-gery,**  H,  A,  Kelly  and  C.  R  Noble,  1907, 
p.  669).  Often  these  tumors  become  progressively  indurated, 
esprially  after  the  mrriopuuse. 

Colloid  or  Myxomatous  Degeneration. — This  is  characterized  by 
the  effusion  of  niueous  material  between  the  muscle  bundles,  the 
mucin  and  proliferation  of  round  cellst  in  the  inter-stitial  tissue 
disi  inguishing  it  from  edema.  Noble  found  myxomatous  degen- 
eration in  3.4  per  cent  of  his  2/274  cases. 

Small,  hanl  tumors  are  found  at  autopsies  on  old  women,  their 
pn\st»nce  not  ha\ing  been  detect^nl  during  life, 

Fibro-cystic  Tumors. — ^Tht^se  tumors  residt  from  the  breaking 
down  and  liquefaction  of  areas  of  degeneration  in  fibroids  and  the 
fusion  of  diffen^nt  foci  by  the  absorption  (if  the  di\'iding  partitions. 
The  degenerated  areas  are  separated,  not  by  distinct  walls,  but  by 
portions  of  the  fibrous  structure  of  the  tumor.  These  tumors  are 
not,  as  formerly  thought,  a  separate  class  of  timiors. 

Doleris  [Archiv.  de  (ocrdoffie,  jariv.  et  f^v.,  lS8.'i  pp,  1  and  354), 
noted  a  proliferation  of  eonnective  tinsue  l>ecoming  colloid  in  a 
fibroid  tumor  during  pregnancy.  After  tlehver}^  it  is  supposed 
that  the  diminution  in  the  nizc  of  a  fibroid  is  due  to  fatty  degen- 
eration. 

Calcification. — ^This  is  rather  a  rare  transformation  which  Noble 
{he,  cit,)  found  m  1.7  per  cent  of  his  cases.  Deposits  of  phos- 
phate and  carbonate  of  lime  are  found  near  the  peripher)"  or  the 
C4?nter  of  the  tumor  and  make  r*itlier  a  bony  framework — ^not  true 
bone,  however — or  a  shell.  Rarely  is  the  tumor  solidifietl  to 
mike  the  so-called  **  uterine  stone."  Small  areas  of  calcification 
are  not  uncommon. 

Fatty  Degeneration. — Gusserow  (**  Die*  Neubildungen  des  Ut^:*- 
nis/'  1886)  ha^  callcnl  attention  to  the  fact  that  fatty  degeneration 
of  a  fibroid  tumor  has  been  determined  microscopically  in  only  three 


254 


DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 


cases — ^those  of  Freund,  A.  Martin,  and  Brunings — where  there  has 
not  been  resulting  diminution  in  the  size  of  the  tuinor  as  well. 
There  is  a  form  of  fibroid  tumor  called  lipomyonia  in  which  a  por- 
tion of  the  tumor  is  composed  of  fatty  tissue. 

Edema. — Edema  is  often  present  in  fibroids  and  may  be  con- 
sidered a  beginning  stage  of  necrosis.  It  most  often  affects  the 
sul^serous  tumors. 

Amyloid  Degeneration. — ^A  single  case  of  amyloid  degeneration 


Fig.   108. — ribroicl  of  the  GtTvix   Distending  the  Vagina.     (After  Dartigiies.) 


of  a  fi]:)roi(l  polypus  has  been  observed  by  Stratz.  {Zeit.  /.  Geburts. 
u.  ihjn..,  1889,  Bd.  XVII.,  H.  1,  p.  80.) 

Suppuration. — This  is  the  result  of  the  infection  of  the  tumor 
with  bacteria  deprived  from  the  intestinal  canal,  the  genital  tract, 
or  the  blood.  Prolonged  pressure  of  a  tumor  on  the  bowel,  or  an 
appendix  vcM-miformis  adherent  to  the  tumor,  may  permit  easy 
pcMietration  of  inicroin-ganisms.  Instrumental  or  digital  invasion  of 
the  uterine  cavity  for  exploration  or  curetting  may  infect  a  fibroid, 
espi^cially  a  submucous  myoma. 

Gangrene. — (langrenc^  may  n^sult  when  a  tumor  is  undergoing 
dt^generation,   or   when   there   is   toi-sion   of   its  pedicle.     Micro- 


COMFLRATrONS 


255 


organwmris  nmy  or  may  not  play  a  part  in  tht*  iieerobiotic  process. 
The  nuThatiism  of  the  pi-ocess  is  obscure.  Extreme  torsion  of  a 
tunior,  caui^ing  stai^is  of  the  blcxxl  supply  and  iieemsit?  or  gangrene, 
18  a  ran*  rornplieation  of  fihruitl  tunitu's,  ZangemeiHler  thought 
that  the  fibroid  uterus  when  rotated  showed  eonnnonly  (21  times 
to  3)  a  torsion  to  the  right  j^ide. 

Thrombosis. — Thrombosis  of  the  IJmxl- vessels  of  a  filiroid  nmy 
oceur.  It  is  probable  that  the  turuor  i.s  tohTated  in  tlie  Ixnly  fur 
a  long  time  after  the  blood  J^upply  is  cut  off  Ix'fore  it  Ix'ooines  in- 
fected, just  a^  in  ca^t^s  of  neglected  extra-uterine  pregnancy  in  the 
late  months. 

Sarcomatous  Degeneration.— This  tJccurrt^Hl  in  two  pi*r  cent  of  the 
CBses  collected  by  Noble  (/oc.  ciL),  and  Winter  {Zeiis,  fiir  Geburts. 
uvd  Gijmkol,  Bd,,  LVII.,  II.  1,  11W)6,  p.  19)  found  sMrroma  in 
4.3  |XT  cent  of  2.Vi  ea>ies  of  fil>roid  tiuiior  in  which  sections  were 
token  J5)^stejiiaticaily  from  different  i>arti5  of  all  tumor's. 


COMPLICATIONS 

Carcinoma  occurs  a.s  an  associated  lesion  in  fibmitl  tmncji-s,  not 
a«f  a  degeneration,  for  w^e  know  that  the  two  processes  ai*e  distinct 
hjHtologically,  with  the  excr|ition  of  a  few*  cases  of  adenomyoma 
when^  cancer  has  \x^vn  ilescrilMsl  as  s|*ringuig  ihreet  from  tlie 
glands;  within  the  tumor.  lu  n  study  <»r  4,880  consecutive  cases 
of  fibroid  tumor,  Nobh^  t/oc.  ciL)  found  that  cancer  was  present  in 
2,8  f^er  cent.  In  his  jK^rsonal  expi^rience  with  337  fibroids,  cancer 
of  the  corpus  was  prest^nt  in  2.6  jx^r  cent,  and  cancer  of  the  cervix 
in  1.4  per  cent;  hence,  as  women  not  the  subject  of  fibroiil  tumor 
have  cancer  of  the  crrvix  ten  times  to  one  foi-  c^aneer  of  the  corpus 
uteri,  he  condudrd  that  tliere  is  a  eausal  relation  iK'twt^en  fibroma 
and  cancer  of  the  lx>dy  of  the  uterus  (a<leno*carcinoma  of  the 
eiidonu'trium). 

Metastases.— Fibroid  ti.ssue  can  h^  in  varied  and  destroyeil  by 
an  epithe'lial  growili.  The  most  frequent  comliination  is  occurrence 
of  carcinoma  of  the  body  of  the  uterus  coincident  with  fibro-myoma. 
Sfimetimes  a  fil)mid  tunmr  intrudes  in  its  tissues  glandular  elements 
flerivi**!  from  the  iluets  of  Miiller  or  Wolff,  and  these  elmients  are 
^ubjecjt  to  a  citrcinomat us  transformation.  X,  Btiider  and  G. 
I^rtlennois  {BxM,  Sac,  Anat.,  lOtW,  No.  8,  Octobre)   have  shown 


109. — Large  Globular  Fibroid,  the  Lower  Part  Filling  the  OnHty  of  the 
PelviB,  Simulalmg  Pregnancy  at  Term.     (Kelly.) 


alone  were  affected.  Aiiiong  L39  causes  gathered  from  the  litera- 
ture in  addition  to  his  own  cases  he  found  lesions  of  the  tubes  32 
times,  alterations  of  the  ovaries  alone  79  times,  and  tuho-ovarian 
disease  28  times.  Among  70  eases  observ^ed  in  Pozzi's  clinic  the 
most  common  lesions  were  catarrhal  salpingitis,  purulent  salpin- 
gitis, hematosalpinx,  and  cystic  degeneration  of  the  ovarias.  In 
Noble's  2,274  cases  of  fibroid  tumor  (loc,  cit.,  p.  668),  complications 
in  the  uterine  appendages  or  in  the  pelvis  existt^  in  37  per  cent. 
In  Pozzi's  chnic  lesions  of  the  tubes  and  ovaries  occurred  in  59 
per  cent  of  the  myoma  cases. 


EFFECT  OF  FIBROID  TrMORS 


157 


In  thi!  anal>*sis  of  those  ^tati8ticB  it  is  luit  to  Ix*  forgotten,  how- 
ever, that  these  large  percentages  were  among  women  whose 
fibroid  tumors  nujuiriHl  .surgical  treatment;  they  had  entered  the 
hof^pital  for  Ojieration.  It  is  hardly  fair  to  a^^uine  that  all  fibroids 
■  are  subject  to  complications  to  the  same  extent;  in  fact,  this  is  an 
objt*ction  to  mo.st  of  the  statistics  which  have  to  do  only  with 
fibroid  tumors  causing  Bymi>toms  of  a  severe  grade. 


r 


I 


I 


EFFECT  OF  FIBROID  TUMORS  UPOH  NEIGHBORING  ORGANS 

The  uterus,  being  attai*heil  to  the  vagina,  to  tlie  uterine  liga- 
ments, and  to  the  {>eritoneimi^  is  nioiv  or  less  liniitefl  in  its  move- 
mt^nts.  If  a  fibroid  tumor  deveIo[»s  in  its  substanc(%  the  uterut^ 
may  ilispiace  the  blailder  or  press  tht*  rectum,  urethra,  or  ureters 
against  the  bony  framework  of  the  jx^lvis.  In  the  case  of  a  fibroid 
of  the  posterior  uterine*  wall,  the  cervix  ma}"  press  on  the  urethra 
and  cause*  retention.  But  this  is  a  rarity.  The  bladder  is  extremely 
tolerant  to  misplacement  liy  a  tumor,  IIowcvit,  retention  is  some^ 
time^  caused  in  this  way,  ant  I  congestion  of  the  vesical  mucosa, 
which  exists  in  the  cas«*  of  fii^roids  as  dctiTminetl  by  Zukerkauill 
thniugh  cystoscopie  examinations  (A.  W'uot,  Annaka  de  gijn.  et 
d'ijbstet,  1907,  2  s..  IV.,  287-310),  fur'nislies  a  favorable  soil  for  the 
growth  of  bacteria  that  may  be  introduecMj  by  a  catheter.  Injmy 
of  the  ureters  an<l  kidneys  from  pressure  on  tlie  uret<*rs  is  much 
more  frequent  than  thought  formerly.  Knox  has  refKjrte^J  a  series 
of  eases  of  compression  of  the  ureters  observed  during  operation 
on  fibroids  at  the  Johns  Hopkins  Hospitak  Of  the  different  vari- 
eties intraligamentous  growths  and  tumors  developing  from  tlie 
errvix  are  most  apt  to  compress  the  ureters  and  also  to  tlisplaeo 
them  upward. 

It  is  difficult  to  say  even  ap[iroximateIy  just  wliat  is  tht*  fn*- 
([uency  of  R^nal  iliseast*  because  of  ureteral  comijression  by  fibrtJid 
tumors,  J.  C.  Web«4er  fomid  n»nal  complications  due  to  fibroids 
in  30  per  cent  of  lOt)  cASl^'*— on  the  other  hand,  Ilaidtain  in  120 
caf«es  had  never  met  renal  coni|>lications,  C*uI!ingvvoi1h  met  liydro- 
lirphnisis  due  to  compression  in  2  out  <jf  lt)0  casi/s:  Sarwey,  1  in 
430  eaBPit:  Knox,  3  in  4(X);  A.  \imoi  points  out  that  the  rom- 
prcsdion  of  tlie  ureter  is  probably  intennittcnt,  due  to  the  motion 

17 


258        DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

of  the  fibroid;  therefore  symptoms  due  to  the  compression  are  not 
present  with  any  definite  regularity. 

Interference  with  defecation  due  to  pressing  on  the  rectum  by 
a  fibroid  tumor  is  a  common  complication. 

Tumors  situated  low  cause  the  greatest  degree  of  interference 
with  the  enlargement  of  the  uterus  during  pregnancy  and  with 
deliver}'.  Fibroids,  then,  are  a  cause  of  abortion.  Lefour  (Th^se 
d*agr6g.  de  Paris,  1880),  out  of  307  cases  of  pregnancy  compli- 
cated by  myomata,  noted  39  abortions  (12.7  per  cent),  the  mother 
dying  in  14  cases.  Nauss  (These  de  Halle,  1882),  out  of  241 
castas,  found  that  al)ortion  took  place  in  47,  or  15  per  cent.  The 
tumors  situated  low  in  the  pelvis  obstruct  delivery;  if  situated 
elsewhere  in  the  substance  of  the  uterus  they  generally  interfere 
with  involution  and  are  the  cause  of  post-partum  hemorrhages. 
Although  the  presence  of  a  fibroid  is  by  no  means  a  bar  to  the 
occurrence  of  pregnancy,  it  is  a  frequent  cause  of  sterility.  OL^ 
hausen  gathered  the  statistics  of  nine  difi'erent  observers,  including 
Scanzoni,  von  Winckel,  Schroeder,  and  Hofmeier,  and  found  that 
out  of  1,731  married  women  with  fibroid  tumors  520,  or  30  per  cent, 
were  sterile.  He  considers  this  figure  too  high,  however,  because 
many  women  with  fibroids  come  under  a  physician's  observation 
only  because  of  sterility,  and  those  who  become  pregnant  often  do 
not  consult  a  physician  at  all. 

EFFECT  ON   DISTANT   ORGANS  AND  ON  THE  SYSTEM 

Anemia  from  prolonged  and  repeated  hemorrhages  is  one  of  the 
most  connnon  results  of  fibroid  tumors.  The  hemoglobin  may  be 
reduc(Ml  as  low  as  thirty  per  cent  or  even  less  and  the  red  cells  to 
1,()0(),0()0.  The  affection  is  a  serious  one  and  diflftcult  to  correct 
ofti^n,  even  after  the  drain  of  blood  has  'been  stopped.  Acute 
hemorrhage  in  fibroid  cases  seldom  proves  fatal,  but  the  continued 
loss  of  blood  produces  a  condition  of  lowered  vitality,  and  a  dis- 
position to  thrombosis,  emlx)lism,  and  phlebitis  that  counter- 
indicates  in  many  cases  an  operation  for  the  removal  of  a  tumor. 
Many  autliors  state  that  the  hemoglobin  should  be  at  least  fifty 
per  cc^nt  before^  a  hysterectomy  is  undertaken.  Kelly  and  CuUen 
howx'vcM',  {loc.  cit.y  pp.  A'hi  and  4r)4),  report  twenty-two  cases  of 
operation  for  the  removal  of  myomata  in  w^hich  the  hemoglobin  was 


RELATION  OF  FIBROID  TUMORS  TO  HEART  DISEASE       259 

forty  per  cent  or  lesi^,  with  a  moi-tality  of  thj-ef^  case8.  It  ofteo  hap- 
pens that  several  years  elapse  before  a  profouiitUy  anemic  patient 
regains  goocl  health  after  the  cause  of  the  loss  of  blood  has  been 
removed* 


RELATION  OF  FIBROIB  TUMORS  TO  HEART  DISEASE 


m 


Tlie  frefiiicney  of  eardiao  palpitation  in  fibroid  tumors  has  been 
refcrreil  to  by  me.  {Amer.  Jour.  Obdei.,  Vol,  XXIX.,  No,  3,  1894.) 
The  qrmptom  appears  to  be  quite  mdepenclent  of  actual  cardiac 
di8i:*ase,  there  being  no  e\i(lences  of  enlargement  of  the  heart  or 
of  adventitious  murmurs.  It  is  possible  that  ]ialpitation  may  Ix: 
due  to  anemia,  in  which  event  one  t^xjii'cts  to  find  heniir  nmrnuu's, 
and  some  influence  must  Ije  a^ssigned  to  the  menopause  in  patients 
who  are  in  tins  time  of  life.  (See  Chapter  XXIX.,  page  613,) 
Tlie  exact  relation  of  these  tumors  to  heart  disc^a*^*  is  not  known. 
Certain  degenerative  changes  in  the  heart  and  in  the  blocMl- vessels, 

eh  as  bro\nj  atrophy,  fatty  degeneration,  fatty  infiltration  of  the 
eart  muscle,  also  chronic  endocarditis^  and  aiteriosclerosis  of  the 
arteries  have  Ix^'n  notetl  by  stutlents  of  this  tjuestion,  notably  by 
Hofmeier,  Fenwick,Strassnmn  and  Lc^hniann,  Boldt,  Pellanda,  Win- 
ter,  and  Heck,  as  quoted  by  Nol>ie  (/or.  cit.,  p.  671).  Winter  found 
the  heart  piM-feetly  normal  m  60  per  cent  of  266  easels  examinetl 
with  reference  to  this  point;  vaKnjlar  disease  was  found  in  but  I 
per  cent,  and  dilatation  and  hypertrophy  in  but  6  per  cent,  the 
oxaminations  being  made  in  every  case  by  a  specialist  in  internal 
inedirine. 

It  is  difficult  to  umlt*rstand  how  lesions  of  the  heart  can  1k' 
causi^l  by  tumors.  I  thuik  w^'  may  agree  witli  Winter  that,  ui 
the  present  state  of  om*  knowledgi\»  w^e  must  attribute  alm*)st  all 
of  the  cardiac  symptoms  in  cases  of  fibroid  tumors  to  anemia,  anti 

nfieciuent  derangement  of  the  nervous  system.  It  is  well  to  re- 
member,  however,  that  hiart  dis*'a^  not  infrefjuently  accompanies 
fibroids,  although  not  necessarily  in  a  causal  relation. 


260         DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 


DANGEROUS  TO  LIFE 

Fibroid  tumors  may  be  a  direct  menace  to  life.  Pellanda  (C. 
Pellanda,  *'La  Mort  par  Fibromyomes  Ut^rins/'  Paris,  1905),  in  a 
study  of  171  cases  of  death  from  fibromyomata  without  operation, 
states  that  in  6.4  jkt  cent  of  the  fatal  cases  death  was  due  to 
hemorrhag(\ 

Acute  alxlominal  emergencies  due  to  torsion  and  infection  of  a 
tumor  are  by  no  means  unknown.  Rupture  of  the  uterus,  due  to 
fibroids  ol^structing  lalx)r,  has  occurrtHl.  As  a  rule,  how^ever, 
these  tumors  endanger  life  indirectly  through  their  degenerations 
and  complications,  through  interferc^nce  with  the  function  of  other 
organs,  and  by  their  effect  on  the  general  health — ^aneniia  and  its 
consequences. 

SYMPTOMS 

Th(*  symptoms  of  fibroid  tumors  are  hemorrhage,  anemia,  pain, 
and  leucorrhea,  also  constipation,  freciuency  of  micturition,  ret(Mi- 
tion  of  urine,  and  dysuria;  the  last  four  being  the  result  of  pres- 
sure on  rectum,  ureters,  un^thra,  or  bladder. 

Hemorrhage. — Hemorrhage  may  be  of  the  type  of  menorrhagia 
or  of  metrorrhagia,  more  often  the*  former.  It  is  a  sjmiptom  nu^t 
with  in  the  submucous  tumoi-s,  occasionally  in  the  interstitial,  and 
not  at  all  in  the  subserous.  As  most  fibroids  are  multiple  it  is 
not  always  easy  to  say  which  form  pnnlominates  in  any  giv(*n 
case.  TIic  submucous  varieties  cause  hemorrhage  by  enlarging 
the  surface  of  tlie  (Midometrium,  the  total  number  of  square  inches 
being  increased  many  times  in  tlu^  case  of  large  tumors. 

Diapcdcsis  of  hmI  blood  cc^lls  through  the  walls  of  the  capillaries 
of  th(*  endometrium  takes  |)lace  to  a  greater  extent  the  larg(T  the 
surface  involved,  but  venous  congestion  caused  by  the  prc^^ure 
of  the  tumor  on  the  thin-walled  veins  is  supposeil  to  be  at  the  root 
of  the  mechanism  of  heniorrhag(^  in  fibroid  tumors;  the  arteries, 
with  th("ir  thicker,  elastic  walls,  being  able  to  withstand  better  the 
|)n»ssure.  The  (lowing  may  be  only  slightly  increased  over  normal 
or  it  may  amount  to  an  excessive  luMiiorrhage  requiring  active 
treatment.  The  size  of  the  tumor  bears  no  relation  to  the  amount 
of  the  (low,  the  small  tumors  often  having  the  greatest  flowing. 


SYMPTOMS 


2(il 


It  fe  a  curioas  fact  tfmt  sonir  womi'H  witli  filjroiil^  flow  more  wliiii 
they  are  lying  down  tliati  tht'V  do  wlnii  iijj  iintl  about;  tlieirfun* 


tl 


\v  trt*atmcnt  in  ^iit'ii  casi*s  is  not  rrst  m  Ixii.  Uiis  iK'ciilianty 
shoiihl  tie  looked  for  in  getting  the  history.  An  active  acute 
lietnorrhagc  i«  generally  not  po  serious  in  its  effect-s  on  the  systeni 
m  a  lesser  liloeiling  lasting  ovei*  months  and  yeaiv. 

Anemia* — Anemia  t^xists  so  fre(|ueiitly  in  film  ml  tumors  that  tho 
jihysician  should  lx»  on  tlie  lookout  for  a  i)ale  fa<*e,  lips  without 
Riucu  color,  eyes?  a  pearly  white,  muscles  rather  flabby,  pul.se 
bounding,  hut  soft  and  compressible,  with  intTcascHl  rapidity  on 
the  sliglitest  excitement.  Besides  palpitation  a  feeling  of  faint- 
nc*?^  aiiii  bn^athlessness  and  languor  accompanies  anemia.  In  some 
cusi»j<  tliere  is  swelling  of  the  ankles.  Th(*  red  hUnMl  cells  may  fall 
to  one-fifth  or  less  of  the  normal  nnmlxT  (1,(M)(),(MM)  per  cubic 
niillinieter),  and  the  hemoglobin  to  thirty  f>er  ci-nt.  lieotic  heart 
munuurs  are  asually  piTsent. 

Pain. — Pain  may  or  may  not  be  present  in  fibroid  tumors,  and 
when  it  does  wcur  is  varial>le  in  amount.  It  is  either  rc^feiTed  to 
the  ut<*njs  or  to  othtT  organs  when  doe  to  pressure  on  surround- 
ing stnictures.  It  assumes  several  forrns,  occuiring  as  a  diilb  con- 
stant i»ain  situatetl  in  one  or  lM»th  groins  or  across  the  alxlomf*n, 
as  a  bt»aring-down  pain,  or  as  a  backache,  and  these  ^^arieties  may 
exiM  si*parately  or  conjointly.  It  may  be  referretl  to  the  thighs  or 
the  leg^  in  consequence  of  the  pn^ssure  of  the  tumor  on  the  sacral 
plexus  of  nerves.  Pressure  on  a  ureter  may  cause  {>ain,  but  the 
n*ctmn  and  l>ladder  are  generally  tolerant  of  jiressmv  s<j  far  as  pain 
is  concerned,  their  disturbance  when  [jresseil  upon  showing  itself 
in  derangement  of  function.  Dysmi^norrhea  occius  in  aliout  twenty 
per  cent  of  the  cas<*s  of  fibroid  tumors^  the  cramiJ-likf*  j>ain  Imng 
often  sincere.  It  must  b*^  rememlxTeil,  however,  that  an  uncom- 
plicated fibroi<l  raivly  give*  rise  to  much  pain,  and  therefore  tlie 
prtMcnce  of  pain,  especially  if  severe,  indicates  an  inHammatoiy 
complication^  such  as  salpingitis  or  atlhesions.  A  rapidly  grow- 
ing tmnor  is  apt-  to  cause  pain  which  Is  referred  to  the  utenis. 
Expulsive  f^ains  an*  found  whim  a  subnmcous  tumor  lx*conies 
peclunculated  and  can  tie  extnKknl  either  in  part  or  wholly  at  the 
extemal  <^s,  Kelly  and  Cullen  found  tJiat  tunjors  of  moderate  siasc 
eausi*d  the  most  pain. 

Leticorrbea.— A  vaginal  tlischarge  is  rare  in  £broids  except  in 


262        DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

the  submucous  variety.  In  this  form  it  is  common  as  a  white 
discharge,  and  if  the  tumor  is  necrotic  the  discharge  is  muddy, 
watery,  and  malo<.lorous.  A  profuse  watery  discharge  associated 
with  fibroids  should  always  excite  suspicion  of  cancer. 

Symptoms  of  Adenomyoma. — ^According  to  Cullen  this  variety 
of  myoma  is  most  prevalent  between  the  thirtieth  and  sixtieth 
years  and  does  not  tend  to  cause  sterility.  Lengthened  menstrual 
periods  are  the  first  symptoms  and  the  flowing  gradually  assumes 
the  proportion  of  hemorrhages.  There  is  pain  with  the  period 
that  is  referred  to  the  uterus;  it  may  be  grinding  in  character. 
There  is  no  intermenstrual  vaginal  discharge  and  microscopical 
examination  of  scrapings  shows  the  uterine  mucosa  to  be  normal. 


DIAGNOSIS   AND    DIFFERENTIAL    DIAGNOSIS 

The  diagnosis  of  large  fibroid  tumors  is  a  comparatively  easy 
matter,  but  the  diagnosis  of  small  ones  is  often  difiicult.  The 
symptoms  are  not  of  much  assistance,  except  that  painful  menstru- 
ation beconiing  profuse  and  protracted,  and  a  history  of  sterility 
or  early  niiscarriag(\<,  are  suggestive  of  fibroids.  The  chief  reliance 
is  the  bimanual  palpation;  and  the  passage  of  the  uterine  sound  is 
most  us(»ful.  The  first  point  to  determine  is  the  relation  of  the 
tumor  mass  to  the  body  of  tlu*  uterus. 

Subserous  Fibroid  Tumors. — If  the  tumor  is  a  single  mass  bi- 
manual palpation  shows  that  it  is  connected  with  the  uterus. 
To  determine  this  point  place  the  tip  of  the  forefinger  in  the  vagina 
on  the  cervix.  On  mo\nng  the  tumor  with  the  other  hand  on  the 
aUlomen,  note  whetluT  the  cervix  moves  at  the  same  time.  Out- 
line the  growih  as  exactly  as  the  laxity  and  thinness  of  the  ab- 
dominal walls  will  permit.  In  some  cases  of  small-sized  tumors  in 
woiiicu  with  thin  parietes,  it  is  possible  to  map  out  the  ovaries, 
and  an  attempt  should  Ix'  made  to  do  this  in  every  case.  If  the 
tumor  is  pedunculateil  it  nuist  Ix'  diflferentiated  from  an  ovarian 
ci/fit.  This  is  (lone  by  detecthig  fluctuation  in  a  cyst.  Making 
firm  pressun^  against  the  tumor  with  the  finger  in  the  vagina,  taps 
with  the  linger  of  the  hand  on  the  abdomen  are  transmitted  to 
th(^  finger  in  the  vagina  as  waves.  The  pedicle  of  a  pedunculated 
myoma  may  be  palpated   by  drawing  down  the  cervix  with  a 


DIAGNOSLS  AND  DIFFERENTIAL  DIAGNaSIS  263 

VTil^IIatii,  which  ia  pa*^sed  to  an  asj^i^taiit  to  hold  while  the  bi- 
manual recto-alxlomina!  touch  in  practised.  (See  Fig.  126,  page 
301.)  If  the  content.^  of  the  f*yst  are  thiek  and  semisolid,  avS  in  the 
case  of  dennoid  oyst?^,  the  fluid  waves  will  be  absent.  Some  ova- 
nan  cysts  are  as  hard  as  some  fibroids,  especially  soft  filiroids. 
As  a  rule  the  fibroids  are  imiltiplc  and  thci*e  is  more  than  one 
nodide  to  be  reckoned  with;  not  only  that,  !>ut  the  nodules  are 
usually  of  a  stony  hardneas.  If  the  fibroid  tumor  or  tumors  are 
large  enough  to  distend  the  aklonien  the  uterus  is  drawn  up  in  the 
pelvis.  This  upward  excursion  of  the  uterus  does  not  take  place  in 
the  ease  of  an  ovarian  turmor. 

Fibroma  of  the  ovary  has  b*en  mistaken  for  a  pedunculated 
suljt^erous  fibroid.  Here  only  an  alxiominal  operation  can  clear  up 
the  diagnosis.  The  sound  shouli!  Ix*  pa-^s<xl.  Fibroids  are  so  often 
multiple  that  a  lengthent?d  canal  may  indicate  a  submucous  or  an 
interHtitial  fibroid  and  therefore  indirectly  point  to  a  subserous 
tumor.  Before  passing  the  sound  observe  strict  antiseptic  precau- 
tions and  always  uiquire  as   to  the  date  of  the  la.^t  nienstnia- 

ti0D» 

Pelmc  injlammaiory  exuviate  may  complicate  a  fibroid  tumor,  but 
\b  seMom  mistaken  for  it.  The  mass  in  inflammation  is  brawny  and 
fills  in  the  chinks  of  the  i>elvis.  There  is  a  histor}'  of  fever,  even 
if  it  is  not  present  at  the  time,  as  shown  by  the  thermometer. 

Cancer  of  the  pelvis,  originating  in  the  uterus  or  ovaries,  may  be 
nxistaken  for  fibroid  tumor,  but  is  difTorentiattHl  by  the  fixity  of 
the  infiltration,  and  the  lat'k  of  definite  outline  of  the  tumon 

Ascites  is  occasionally  present  in  large  tumors.  Change  of  posi- 
tion of  the  patient  (*hanges  the  situation  of  the  fluid,  which  is 
mapped  out  by  its  flatness  to  percussion. 

The  contour  of  the  alxlomen  in  the  ca*^  of  large  fibroids  is  dome- 
shapeil  if  the  fibroid  is  globular  and  single,  nodular  if  nmltiple. 
The  tumor  stands  out  sharply  on  all  sides  when  seen  in  profile, 
tSee  Fig.  103,)  Ascites,  if  it  is  jiresi^'nt  in  excess,  modifies  the  contour. 

Intraligamentous  Fibroid  Tumors. — ^An  intrahgamentous  fibroid 
\»  situated  at  one  side  of  the  uterus,  the  sound  showing  the  situa- 
tion of  the  latter  if  it  can  not  be  palpatcn:!.  This  sort  of  tumor  is 
low"  in  the  pelvis,  often  it  can  be*  felt  projecting  into  the  vagina. 
Its  mobility  is  limitetl  because  of  its  attachments  and  its  situation. 

iDterstitiAl   Fibroid   Tumors. — The   uterine   canal   is   conunonly 


204         DIAGNaSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

lengthcne<l  in  cases  of  interstitial  fibroids,  and  hemorrhage  is  likely 
to  occur  in  these  tuinoi-s.  In  this  variety  the  enlargement  of  the 
uterus  may  Ix*  symmetrical,  or  it  may  be  asymmetrical.  In  the  lat- 
ter, the  diagnosis  is  easier  to  make;  in  the  former,  one  must  rule 
out  pregnancy.  To  do  this  it  is  important  to  get  the  history  most 
carefully,  having  regard  to  amenorrhea  and  nausea.  The  elastic 
feel  of  the  pregnant  uterus  is  to  l^e  sought  for,  also  the  softening  of 
the  cer\'ix  and  the  bulging  of  the  anterior  segment  early  in  preg- 
nancy and  ballottement  later.  (See  Chapter  XXII.,  p.  423.) 
Breast  changes  are  to  be  looktnl  for,  and  if  the  tumor  is  large  an 
attempt  should  be  made  to  auscult  the  fetal  heart  sounds.  An- 
other examination  a  month  later  will  confirm  a  diagnosis  of  preg- 
nancy. 

A  fibroid  rarely  Ix'comes  cystic  before  it  has  attained  the  size  of 
a  three  months'  pregnancy;  therefore,  an  elastic  tumor  of  less 
than  this  size  is  probably  not  a  fibroid.  The  sound  is  not  to  be 
passed  if  there  is  the  slightest  suspicion  of  pregnancy.  Examina- 
tion under  ether  is  advisable  if  the  abdominal  walls  are  tense  or 
the  conditions  for  examination  are  not  entirely  satisfactor5\ 

Sarcoma  may  develop  in  a  fibroid.  In  this  event  the  tumor  has 
grown  rapidly.  Only  ojxTation  makes  a  positive  diagnosis  of  sar- 
coma. 

Submucous  Fibroid  Tumors. — A  historj'  of  hemorrhage  is  present 
in  almost  all  submucous  fibroids.  Here  the  diagnosis  is  established 
by  the  sound  and,  if  necessary,  by  digital  exploration  of  the  uterine 
cavity.  Bimanual  palpation  determines  an  increase  in  size  of  the 
uterus.  This  is  true  even  in  the  case  of  small  growths.  Tlie 
sound  shows  enlargement  and  distortion  of  the  uterine  cavity. 
If  the  tumor  is  at  the  fundus  notliing  but  digital  exploration  will 
settle  the  question  wh(*ther  it  is  sessile  or  pcnluncidated.  Some- 
thing may  be  learned  often  by  the  tactile  sense  transmitted  through 
the  exi)loring  sound.  To  make  a  digital  exploration  of  the  uterine 
ca\ity  th(»  cervix  is  to  lx»  dilated  by  a  series  of  dilators:  the  Hanks, 
followed  by  the  Wathen  or  by  large  Simon  dilators,  plenty  of  tinu^ 
Ixnng  taken  so  that  rupture  may  not  occiu*.  In  cases  of  hard, 
resistant  ccTvices  it  is  Ix^st  to  adopt  the  method  of  incision  of  the 
antcTior  wall  of  the  cervix  descrilxMl  in  Chapter  VII.,  page  94, 
n^pairing  the  cervux  by  suture  after  the  exploration  is  finished.  A 
sessile  submucous  fibroid  of  the  fundus  ut<?ri  may  be  mistaken  for 


DIAGNOSIS  AM)   DIFFERENTIAL  DIACINCW^IS  20.") 

lulrnoiim  or  adcno-carciiioinii.  A  piece  rcinovcil  and  sul)iiiitt('(l 
to  iiiicroscopic  cxainiiiatioii  is  tlic*  only  in(»ans  of  <Hstin<^uisliing 
the  two.  A  iHMluiicuIat(Ml  tumor  presenting  at  the  external  os  may 
Ik'  mistaken  for  inversion  an<l,  if  sloughing,  for  earner  of  the  cervix. 
It  is  distinguished  from  caneer  by  learning  that  the  sound  may 
Ik*  mad(»  to  .^\v(»(*p  entirely  around  th(»  tumor,  thus  making  sure 
that  theeerv'ix  itself  is  not  th(»  seat  of  the  disease;  and  from  inver- 
sion l)y  noting,  l)y  bimanual  reeto-alKlominal  touch  und(T  ether, 
that  the  fun<lus  uteri  is  in  its  normal  situation.  An  invei1(Ml 
uterus  is  usually  very  sensitive  to  touch,  although  not  invariably  so. 
Cancer  of  the  body  of  the  uterus  and  chorioejyithelimna  are  to  be 
exclude*!  by  the  (examination  of  tissue  remove<l  from  the  utcTine. 
cavity  l)y  cun^tting  or  l)y  <ligital  exploration,  and,  in  the  case  of 
chorioej)ith(»lioma,  l)y  the  history  of  a  j)revious  lal>or,  alx)rtion, 
or  hydatidiform  mole  having  occurred  within  a  few  weeks. 


CHAPTER  XVI 

THE     DIAGNOSIS     OF    MALIGNANT    DISEASES    OF    THE 

UTERUS 

Cancer,  Sarcoina,  and  Malignant  Chcjrioepiihdioma 

Cancer  of  the  uterus,  p.  266:  Definition,  p.  266.  Varieties,  p.  266. 
Diagnosis  of  cancer  of  uterus  in  general,  p.  270.  Diagnosis  of  cancer  of  the 
cervix,  p.  271;  Differential  diagnosis  of  cancer  of  the  cervix,  p.  272. 
Diagnosis  of  adeno-carcinoma  of  the  cervical  canal,  p.  275;  Differential 
diagnosis  of  the  adeno-carcinoma  of  the  cervical  canal,  p.  276.  Diagnosis 
of  cancer  of  the  body  of  the  uterus,  p.  276;  Differential  diagnosis  of 
cancer  of  the  body  of  the  uterus,  p.  277. 

Sarcoma  of  the  uterus,  p.  278:  Frequency  and  definition,  p.  278. 
Varieties,  p.  279. 

Malignant  cliorioej)ithelioma,  p.  280:  Definition,  macroscopic  and  mi- 
croscopic apjiearances,  j).  280.  Course  of  the  disease,  p.  281.  Ectopic 
malignant  chorioepithelioma,  p.  282.     Diagnosis,  p.  283. 


THE   DIAGNOSIS    OF   CANCER  OF   THE  UTERUS 

By  cancc^r  of  the  uterus  we  understand  a  malignant  new  growth 
the  essential  eh^nients  of  which  consist  of  epithelial  cells  having  a 
charact(*ristic  arrangement.  The  cancer  cells  may  proliferate  and 
(Hrectly  invacU^  the  surrounding  tissues  or  they  may  be  transported 
by  the  lymphatics  to  distant  sites  and  there  proliferate  and  form 
metastatic  growths. 

Varieties 

The  mu(H)us  membrane^  of  th(»  uterus  may  be  divided  into  three 
types:  (1)  That  covi^ring  th(»  vaginal  portion  of  the  cervix,  extend- 
ing from  th(^  vaginal  vault  to  the  external  os,  and  composed  of 
s(iuamous-celIed  (^pithehum.  (2)  That  lining  the  cervical  canal 
from  the  (external  os  to  the  internal  os,  and  composed  of  high 
cylindrical  (epithelial  cells;  and  (3)  That  lining  the  uterine  cavity 
proptT  from  the  internal  os  to  the  fundus,  and  composed  of  low 

26() 


CANCER  C»F  THE  UTERU8 


267 


indrieal  or  culx)itla!  epithelial  cells.  Cancer  of  f  lie  uterus  al- 
ways originates  in  the  mueoas  ineiiibraiie,  anil  the  type  of  cancer 
is  detennined  by  the  character  of  the  cells  of  the  mucous  mem- 
brane in  which  it  originates. 

We  have  then  three  kinds  of  cancer  of  the  uterus; 
1,  Squamous-celled  cancer  of  the  cervix, 
Adenocarcinoma  of  the  cervical  canal. 
Adeno-i!areinoma  of  the  body  of  the  uterus. 


FlO*  110.— Billy  Slsge  of  Squamous-c*41ed  Cancer  of  tlie  Cem^.     The  Cauli- 
flower Maas  hu5  been  Curetted  away,     (CuUen.) 


Very  rarcJy  there  is  pn^sent  a  Bquamous-celletl  cancer  of  the 
body  of  t  he  uteras. 

1.  Squanmus-celled  cancer  of  the  cervix  begins  at  or  near  the  Junc- 
tion of  the  cervical  and  vaginal  mucous  membranes  at  the  external 
06.  ClinicallVi  three  tj^x^s  are  recognized:  («)  The  everting  or 
cauliflower  gro\\1h,  in  which  there  is  marker  1  proliferation  of  the 

■  cancer,  the  growth  Bpremling  to  and  invoKing  by  rlirect  extension 
the  vault  of  the  vagina,  (h)  The  mflltrating  type,  in  which  the 
external  contour  of  the  cervix  may  remain  nonnal,  the  growth 
extending  internally  deep  int^  the  wall  of  the  cer\ix.     (c)  The 

■  ulocrative  type,  in  which  ulceration  with  loss  of  cervical  tissue  takes 
place  early  and  proceeds  until  the  entire  cervix  is  eroded. 


268     DUGX06IS  OF  M.VLir..VANT  DLHE.%SE8  OF  THE  rTEftrS 

TJjo  i4<|tianioij29-rpiJeil  tyj»  irf  imnrt*r  of  the  cf*rvix  is  URtnIIy 
impiii  growth  and  it  mon  tti\*oKiiis  the  sumrnniGn^  tissues 
QrgBii9 — the  UaddcT,  the  unFters,  aikI  mrlum.    Hie  l\^it>h  gland 
of  the  pannnetritmi  and  t>ie  iliac  ^ands  receive  the  cancer  hyl 
means  of  the  lymph  channels  and  theoidelTBS  take  up  the  disease.! 

Mirroecopieally  the  squamaiis-cdled  t>^  begins  as  an  hyper- 
tnipliy  of  the  i)a\-ement  sqtuunott?  epitbeltum  of  the  eer%ix.    The! 
celk  theni^^vtis  hj^pertrophy  an^l  have  large  round  or  oval  verfc-J 
ular  nuclei   with  many  niitodc  figare&    These  celts  invaiie  tl 


V 


-^- 


Fig.  111.-^ Very  early  Adeoo-Carcinoma  of  the  Cervical  CoqaL     (Cullcn  > 

cervical  tissue  in  all  directions  and  without  any  tjijical  arrangf^ 
ment. 

2.  Adeno-careirumta  of  the  cervical  canal  originates  in  the  high 
cylindrical  epithelial  cell?^  lining  the  cer\'ical  canal  and  the  glands 
of  the  cervical  canal  This  t\T>e  of  cancer  of  the  cervix  sproadi? 
perhai>s  le.ss  ra|)id]y  than  the  sciuamous-eelletl  variety,  although 
necrosis  takes  place  rather  eaiiy.  The  squamons-celled  \^ety 
i^^dom  spn*a<Ls  bc*yond  the  level  of  the  internal  os.  but  the  adeno- 
carcinoma fre<4uerjtly  reaches  to  the  fundus.  The  cervix  may  be 
reduced  to  a  mere  shell  by  the  ntH*rop?is  of  the  latter  form  of  cancer 
and  yet  the  external  contour  of  the  cerroc  n^mains  unchanged. 
Metastaas  to  the  surrounding  organs,  the  bladder  and  rectum, 


4 


taki»s  place  usually  by  dirwl  extension  of  the  grovith.  TUv  iliae 
glands  an*  involved  j^ornetinjes  early  and  sometimes  late,  as  is  the 
Cai^  with  the  .^f|uanious-e(4Ied  variety, 

Mieroseopi rally  adini(>(*nrrint)ma  of  the  eemx  is  recognized 
as  a  proliferation  of  the  eylindrieal  cells  of  the  cervical  niucoiis 
membrane,  thest*  cells  preservdng  their  alveolar  or  glandular  ar- 
rangement, Tliere  is  distinct  loss  or  erowrling  out  of  the  inter- 
glandular  stroma,  the  proliferathig  alveoli  lying  close  to  one  anothi/r. 

3,  Adeno-cartincffm  of  the  body  of  the  uterus  originates  in  the 
low  columnar  epithelium  linhig  the  uterine  canity  and  the  giant  Is 


f^wfisi/i,/^ 


^la.  112,— Eftriy  Adimo-Cttrcinonm  of  the  Body  of  tlif  rteriis.     iX'»illuji.) 

of  the  endonietriuni.  Ir  ustiully  starts  at  the  fundus  or  in  one 
eonm  as  a  eircuniserilK'il  area  of  [jroliferation  of  the  endometrhirrL 
From  tliis  jxjtnt  it  may  spread  until  it  involves  the  entire  uttTine 
canity.  The  grouih  may  proliferate,  fonning  actual  outgrowths 
of  endometrium  into  the  uterine  cavity,  as  well  as  invade  tlu* 
uterine  nuiseular  wall.  The  growth  may  ulcerate  its  way  through 
the  uti'rine  wall  and  ap|M*ar  in  thr  jKTitoneul  cavity  ami  fonn 
pcritonc^al  metastascsft,  Tliis  is  generally  a  lati*  j»rT>ee8s  of  a  long- 
existing  cancer.  The  nrdinary  b»»nign  uti^rine  poly|),  lunng  eoverf**! 
by  endometrium^  may  become  carcinomatous*     Adenoi^areinotna 


270     DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

• 
of  the  body  seldom  extends  beyond  the  mternal  os,  although  adeno- 
carcinoma of  the  body  and  cervix  may  coexist. 

Glandular  metastasis  from  this  form  of  cancer  is  late. 

Microscopically  adeno-carcinoma  of  the  body  is  recognized  by 
the  proliferation  of  the  low  cylindrical  cells  of  the  endometrium 
of  the  fundus,  these  cells  preserving  their  glandular  arrangement 
with  distinct  loss  of  interglandular  stroma.  The  cells  lining  the 
new  glands  are  from  two  to  four  layers  deep  or  possibly  entirely 
fill  the  alveolus. 

Diagnosis  of  Chancer  of  the  Uterus  in  General 

It  is  important  to  keep  in  mind  that  cancer  is  always  a  local 
disease  in  the  beginning  and  that  prompt  removal  of  the  diseased 
tissues  effects  a  permanent  cure;  therefore  early  diagnosis  is  espe- 
cially important.  A  failure  to  make  a  correct  diagnosis  is  followed 
surely  by  the  death  of  the  patient  in  from  six  months  to  a  year 
and  a  half.  Late  operations,  except  in  the  case  of  cancer  of  the 
body,  are  of  value  only  in  prolonging  life  a  few  months  or  a  year 
or  two,  and  in  lessening  suffering.  The  view  commonly  held  by 
the  laity,  and,  sad  to  relate,  by  too  many  of  the  medical  profession, 
that  cancer  is  an  incurable  divSease  is  not  true,  provided  that  it 
(;an  be  nn-ognized  and  removed  before  it  has  gained  a  good  head- 
way. 

It  apj>ears  that  progr(\ss  is  being  made  in  getting  patients  to 
submit  to  examination  at  earlier  periods  of  the  disease.  G.  Win- 
ter's works  in  spreading  a  propaganda,  both  among  the  physicians 
and  tli(i  laity,  in  East  Prussia,  is  most  encouraging  (Zentralblattfur 
(iynOkologie,  1904,  No.  14,  p.  441).  It  is  a  fact,  however,  that  at 
th(*  ])resent  time  a  large  proportion  of  the  sufferers  from  this  dread 
disease  are  permitted  to  get  into  an  absolutely  hopeless  state,  then 
to  go  through  the  awful  months  of  suffering  until  a  lingering  death 
releases  tlu^ni. 

The  symptoms  of  uterine  cancer  are  by  no  means  pathognomonic; 
they  are  sugg(\stive  and  are  as  follows:  Bleeding,  particularly  in 
women  who  have  passed  the  menopause;  and  hemorrhage  or  a 
show  of  blood  [ifter  coitus,  also  a  })ei*sistent  or  recurring  sero- 
sanguinoleut  vaginal  discharge.  Neither  of  these  is  a  symptom 
of  the  normal  menopause,  as  has  been  maintained  in  the  past.    The 


CANCER  OF  THE  UTERUS  271 

menopause  ha^  no  local  symptoms  if  t\w  uterine  organs  are  normal. 
Iilc(»tling  or  a  vaginal  discharge  occurring  at  the  time  of  change  of 
life  shouifl  lead  at  once  to  a  vaginal  examination  to  determine  the 
cause.  Pain  and  cachexia  arc  sympttmis  of  the  advaneecl,  hope- 
le.*^  stages  of  the  disease,  only  at  tliis  time  one  does  not  have  to  be 
a  physician  to  make  a  diagno^i^.  Although  the  disease  occurs 
most  commonly  in  women  wlio  are  Iwtween  the  fortieth  and  fiftieth 
years  it  may  occur  at  any  ag(*  Ix^lween  eight  and  seventy-six. 

Clinically,  heredity  seems  to  play  a  r61e»  though  this  has  been 
disputeil. 

The  ilisc^Ase  is  relatively  rare  in  the  colored  race. 

It  is  more  frequent  among  women  who  have  \jon\e  cliildren  tlian 
in  nulliparae. 

The  diagnosis  varies  with  the  progrcvss  of  the  flisease,  an<l  the 
variety  of  cancer  present;  the  early  stages,  while  the  normal  tissues 
are  being  replaced  by  cancer  cells,  show  only  a  slight  local  thicken- 
ing or  prohferation ;  the  later  stages,  when  tlie  tissues  are  l>reakiiig 
down  and  degenerating,  show  ulceration,  bleeiling»  and  detritus 
with  foul  odor. 

As  has  been  pointed  out  in  describing  the  different  forms  whicli 
cancer  assumes,  the  disease  advances  in  diffenmt  manners  and  at 
different  rates  of  Sjx^ed  in  irKlividunl  cases.  It  may  progress  to  a 
fatal  termination  in  a  year;  on  the  other  hand,  I  have  had  a  patient 
who  had  the  erosion  t\^>e  of  cancer  of  the  cervix  where  there  was 
every  indication  that  the  dis(*ase  had  existfHl  for  twenty  years. 
The  tissues  may  be  brittle  and  easily  ilisintegrating,  or  tough  and 
liard.  The  tissues  most  commonly  invaded  Ijy  the  different  kinds 
of  cancer  have  been  noted,  therefore  in  making  a  diagnosis  the 
routes  of  extension  of  the  disease  must  U^  taken  into  account. 
We  employ  both  touch  and  sight  in  making  a  diagnosis,  as  well 
M  microscopic  examination  of  tissues  removed, 

DiAGXDsis  OF  Cancer  of  the  Cervix 

This,  of  all  forms  of  uterine  cancer,  is  the  easiest  of  diagnosis 
because  the  lesions  can  b(»  dr-tected  by  both  touch  aiul  sight. 

(a)  The  catdiflmver  growth  is  the  simplest,  growing  as  it  does  as 
a  polyp-like  mass  j)rojecting  from  the  cerv^ix  into  the  vagina.  In 
tba  early  stages  tliis  appears  as  an  indurated,  reddened  area  raised 


272     DIAGXOSIS  OF  MALIGXAXT  DISEASES  OF  THE  UTERUS 

alx)V(»  the  surrounding  mucous  membrane.  In  its  later  progress 
one  exjxH'ts  to  find  a  larg(T  tumor,  reddish-gray  in  color,  with 
softened,  disintegrattnl  tissue*.  The  sound  i)erforates  it  with  ease, 
and  any  manij:)ulation  causes  lu^morrhage. 

(6)  If  the  injiltratimj  si^rt  is  present  the  tissues  are  indurated  and 
the  contour  of  th(»  cemx  may  Ik»  altered  or  not.  If  the  vaginal 
mucous  membrani*  overlying  the  growth  is  intact  the  diagnosis 
is  difficult.  In  all  suspicious  cases  a  wcnlge-shaixnl  piece  of  tissue 
should  be*  removed  and  submitted  to  the  pathologist  for  micro- 
scopic examination. 

(r)  TJw  ulcerating  variety  is  distinguished  by  an  ulcer  of  exca- 
vating tendency.  There  is  nuich  loss  of  substance;  the  edg(^  of 
the  ulcer  are  rough  and  irn^gular:  the  ba.se  is  necrotic;  the  under- 
lying tissu(\<!  are  hard  to  the  fe(»l.  If  portions  of  the  <leeper  parts 
of  th(»  edge  of  an  ulcer  cmmble  on  pressure  by  the  finger  or  soun<l 
the  condition  is  suspicious  of  cancer:  also,  if  the  edge  of  the  uIcit 
has  a  porky  consistency  an<l  is  of  a  yellowish-gray  color.  In  all 
doubtful  cases  a  piece*  of  tissue  must  Ix*  removed  for  microscopic 
examination.  To  do  this  fix  th(*  cervix  with  a  double  tenaculum 
just  outside  the  diseased  area  and  let  an  assistant  hold  the  tenacu- 
lum. If  the  cervix  proves  to  he  s(»nsitive  inject  into  the  sound 
tissue  surrounding  the  diseascHl  ar(»a,  in  several  places,  a  few  minims 
of  twf)-per-cent  steriK*  solution  of  cocaine  with  a  hy]X)demiic 
syringe.  Wait  five  minutes.  With  a  single  tenaculum  and  a 
scalpel  or  scissors  cut  out  a  good-sized  piece  of  the  diseased  tissue 
in  th(»  shape  of  a  wc^dge.  Be  prepareil  to  place  a  catgut  stitch 
with  a  curved  ncM'dlc*  should  there  be  much  bleeding.  Often  an 
ap])li('ation  of  tincture  of  ioduie  and  carlx)lic  acid  followed  by  a 
dry  tampon  will  hr  sufficient  to  stop  all  bleeding.  The  patient 
shouM  not  be  dismisscHl  until  it  is  known  that  the  bleeding  has 
been  controllcMJ. 

Dijf'crchtial  Diagnosis  of  Cancer  of  the  Cervix 

(a)  Cauliflower  Form. — The  cauh\Hoirer  form  of  cancer  of  the 
cervix  nnist  he  (lifTcrcntinted  from: 

(1)  Follicular  hypcrtropliic  polyp. 

(2)  Mucous  polyj). 

(3)  Paj)illary  tuberculosis.     . 


CANCER  OF  THE  UTERUS 


273 


I 


(4)  Myoma  of  the  cervix. 

(5)  Condylomata  acuminata, 

(1)  TUq  follicHlar  hi/itertrtjphies  of  the  cemx  prormetMlisciTto 
tiimon?,  in  some  cases  similar  to  polypi.  They  are  soft,  of  a  retl 
color,  and  siiow  the  rounded,  yellow,  shot-like,  dilated  Nabothian 
follicles  in  their  substance,  the  contlition  Ix'ing  not  imlike  that  in 
the  tonsiL  The  follicles  may  b<'  seen  and  felt  also  in  tlie  surround- 
ing normal  mucous  membrane  uf  the  nT\ix.  There  is  lacking  the 
crumbling  consistency,  the  sharp  edges,  and  the  imhiraied  Ijase 
of  the  cauliflower  cancer.  The  microscope  ml!  confirm  the  diag- 
nosis. 

(2)  Mucous  polypi,  especially  if  multii>le  and  having  a  lumpy 
apix*arance,  may  be*  niistaken  for  cancer.  Polypi  are  covefed 
ever>n\'herc  with  mucous  meml>rane,  they  are  soft,  and  the  sound 
will  detect  the  position  and  size  and  sliai>e  of  their  iK^dicles. 

(3)  Papillary  tuberculosis^  although  relatively  rare,  may  simulate 
closely  polyp<}id  earcincjma  in  its  early  stages.  The  external  08 
may  I:k*  surromiiletl  by  a  papillary  excrescence.  It  is  jxjssible  in 
favorable  causes  to  iletermine  the  presence  of  the  little  glassy  tubi^r- 
cles  the  size  of  a  millet  seed  lying  in  the  greasy,  chee^  substanci* 
characteristic  of  hroken-dowTi  tulMTculous  tissue.  In  tuberculous 
diseases  of  the  cervix  the  ulceratttl  form  is  more  common  than  the 
papillary.    The  diagnosis  must  be  made  by  the  microscope*, 

(4)  Myoma  of  the  cervix  is  rare.  A  cervical  myoma  is  covercfl 
with  a  smooth  mucous  nif^mbrane,  it  disintegrates  by  ortUnary 
gangrc^ne,  and  has  a  firm  and  not  a  cmmbly  consistency, 

(5)  PoirUed  condylomata  may  simulate  papillary  cancer,  esjiecially 
during  pregnancy.  They  form  a  circumscrilxHl  tumor  of  irregular 
mirfat*e;  but  they  liave  no  infiltrated  base  and  no  real  ulceration, 
only  a  papillary  surface  with  thick  efiitheliurn.  They  are  of  a 
redflish-white  color.  As  a  rule  they  occur  in  more  than  one  situa- 
tion at  th*'  same  time,  i.e.y  on  thr^  wall  of  the  vagina  or  on  the  vulva, 

(7>)  tn^tratiag  Cancer. — Infiltrating  cancer  is  confuscHl  most.  oftc»n 
with  inflammatory  diseases  of  the  cervix  occurring  in  connection 
with  tears,  especially  when  the  tissues  are  indurate<l  and  ncwlular, 
as  ihvy  often  are.  As  a  nile  thi^  inflammator>'  process  involves 
the  entirt*  cervix,  the  consistency  is  not  so  hard  as  in  cancer,  and 
the  external  mucous  membrane  is  not  involved.  If  the  cervix  is 
riddled  with  disciused  Nalx>thian  follicles  the  similarity  of  the  two 
IS 


1 


274     DL4GN0eiS  OF  MALIGXANT  DISEASES  OF  THE  UTERUS 

con^iitions  is  often  great.  But  here  the  cancer  is  limited,  whereas 
the  inflanimator}'  affection  is  universaL  In  all  cases  a  piece  of 
tissue  should  be  removeii  for  examination. 

(c)  Ulcerating  Form. — ^The  ulcerating  form  of  carcinoma  must  be 
differentiatf**!  from: 

1.  Erosion. 

2.  Simple  ulcer:  as  in  prolapse. 

3.  Tuberculous  ulcer. 

4.  Chancroid^. 

5.  SjTDhilitic  ulcer. 

1.  If  there  is  ver>'  Uttle  infiltration  and  induration  a  cancerous 
ulceration  may  simulate  a  simple  erosion y  especially  in  those  cases 
where  the  erosion  has  a  tliick,  roughened  surface.  The  character- 
istics of  the  mahgnant  ulceration  are  to  be  borne  in  mind.  Ako, 
the  erosion  as  s<i*n  through  the  speculum  presents  a  bright  red, 
shining  apjx^aranco,  while  the  cancerous  ulceration  shows  loss  of 
substance  and  a  dull  red  or  yellowish-gray  color. 

The  erosion  has  no  sharp  edge,  but  shows  a  gradual  transition 
of  the  pavement  ej)ithelium  of  the  normal  mucous  membrane  to 
the  erosion  by  a  bonier  of  irregular  outline,  and  there  are  apt  to 
bc»  islands  of  normal  mucous  membrane  in  the  erosion.  If  then? 
is  infection  of  the  en)sion,  scar  formation  results.  In  doubtful 
cases  thf*  iiiicroscojx^  must  Idc  brought  in. 

(2)  Simple  Vlcer.s. — Th(*se  occiu*  in  prolapse;  they  are  generally 
not  situatfMJ  at  the  external  os,  while  the  carcinomatous  ulcers  are 
more  apt  to  Ix'  in  that  situation.  They  are  apt  to  have  a  light 
yellow  l)asc  and  show  cicatrization  about  the  peripherj',  and  there 
are  islands  of  mucous  membrane  in  the  central  portions.  After 
the  prolapsed  uterus  has  been  replaced  for  a  day,  all  traces 
of  infiltration  of  the  tissues  under  such  ulcers  disappear  and 
evidence  of  repair  at  the  edges  can  be  seen.  As  a  rule  there 
is  little  or  no  thickening  of  the  tissues  under  these  ulcers.  This 
is  the  case  also  with  ulcers  caused  by  an  ill-fitting  pessary.  They 
heal  readily. 

(3j  Tuhercukms  Ulcer. — This,  although  rare,  is  very  similar  to 
carcinomatous  ulcer.  Both  an*  generally  situated  around  the 
external  os;  the  base  of  the  tulx^rculous  ulcer  is  yellow  in  color, 
no< hilar  but  not  infiltrated.  Yellow,  miUary  tubercles  may  be 
seen  in  the  mucous  membrane  in  the  neighborhood  of  the  ulcer. 


CANCER  OF  THE  UTERUS 


275 


Th 
■       am 


There  fs  apt  to  be  present  also  tuberciilosiH  of  the  entiometriiim 
and  of  the  tubes.     The  niieroscope  settles  the  diagno^. 

(4)  Chancroids  are  generally  small  in  .size  and  multi|>le;  tlieir 
-se  has  a  tliphtheritie^  gra>ish  appearance,  and  h  not  indurated, 
id  the  edges  are  indented  and  raiseil.     SimUar  lesions  are  to  be 

found  generally  in  the  vagina  and  \"ulva. 

(5)  SyphUitic  ulcer  may  occur  on  the  eervix  in  three  fi>nns;  (a) 
as  an  ulcerated  initial  lejsion,  (b)  as  broken-tiown  papules,  or  (c)  as 
a  degenerated  gumma. 

(a)  The  iniiial  lesion  is  solitary  and  of  great  hardness.  The 
ulcer  has  a  sharp  eflge  ant  1  is  of  a  diiiy  rtMldish-brrmii  color:  its 
diischarge  being  of  a  greasy  consistency.  It  may  extend  into  the 
cervical  canal  in  the  cast*  of  a  parou.s  woman  with  open  os  cxteniunL 

(6)  Ulcers  from  jmpule^H  are  generally  Mmlti[>li»  and  are  e]evate<l 
above  the  surrounding  sm*facr*  of  tlie  normal  mucous  membrane. 
Their  siu^'ace  is  covered  with  disc^rganized  white  or  yellowish  tissue. 
Near  them  are  to  Ix»  founil  non-ulcerateil  papules,  esjx^cialty  m\ 
the  walls  of  the  vagina  and  vuJva, 

(c)  Gummula  of  (he  cervix  are  verj^  ran^.  They  are  described  by 
Neumaim  (Winter*s  *'Lehrbuch  der  Gynakologischen  iJiagnostik/* 
iii,  Auf,)  as  occurring  ab<»ut  the  os  externum  and  on  either  or  br^th 
the  anterior  an<l  ix)sterior  lips  of  the  cervix.  The  ulcers  are  ellij> 
tieal  in  shape  with  sharply  defined  edges,  shallow  or  deep,  generally 
with  yellow  purulent  covering.  (lood-siztHi  fungous  granulations 
an"  apt  to  be  found  on  the  siu-face.  These  ulct^rs  are  to  \n^  differ- 
entiatixl  from  canc*iT»us  ulcerations  by  their  irregular  and  siimous 
borders,  their  rapid  disintegration^  and  the  crater-Uke  excavations 
of  their  tissues.  Syphilitic  lesions  elsewhere  in  the  Ixxly  assist  in 
making  the  diagnosis,  the  niicroseupe  Ix'ing  the  court  of  last  resort. 

DuGNosis  OF  Adkno-carcinoma  of  the  Cbiuvical  Canal 

In  this  form  tlie  diagnosis  is  of  nece-ssity  difficult.  Palpation 
will  show  usually  thickening  of  the  cervix  and  perhaps  a  nodular 
feeling.  If  the  external  os  is  normal,  a  nodular  thickening  and  the 
detection  of  a  bloo<ly  discharge  from  the  os  may  U^  all  of  the  sus- 
picious signs. 

If  the  OS  is  open  because  of  tears,  ulcerated  and  indurate!  areas 
in  the  canal  may  be  both  palpated  by  the  finger  in  the  canal  and 


276     DUGXOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

seen  with  a  uterine  or  bladder  sixx*ulum.  With  the  aid  of  a  sharj), 
stiff-siianktHl  curette,  tis^sue  is  removed  for  microscopic  examination. 

In  the  infihrating  variety  where  there  is  no  ulceration,  palpation 
ha^^ng  shown  localized  thickening  of  the  tissues,  the  external  os 
should  be  (Hlatcnl  under  ether  and  a  piece  of  tissue  excised  for  a 
microscopic  examination. 

In  curetting  the  Ixnly  and  fundus  of  the  uterus  it  is  very  easy 
to  overlook  thic>  situation.  The  physician  should  bear  in  mind 
always  that  the  cervical  canal  is  one  of  the  points  of  origin  of 
cancer. 

Differential    Diatjnoisis  of  Adeno-carcinoma  of  the  Cervical  Canal 

This  form  of  cancer  of  the  uterus  is  to  Ix^  diflferentiated  from 
intcri^tiiial  niyomOj  and  chronic  cervical  endomeiriiis  in  old  women. 

As  to  th(^  fonner,  the  infiltration  of  the  tissues  surrounding  the 
center  of  the  disease  distinguishes  carcinoma  from  myoma.  In 
the  case  of  the*  latter  the  mucous  membrane  of  a  chi-onic  endocervn- 
citis  is  mon*  normal  to  sight,  although  not  necessarily  so  to  the 
touch,  and  the  curette  carries  away  little  tissue.  Tissue  is  removcnl 
and  the  microscopt^  tells  the  last  word. 

Diagnosis    of    Cancer    of    thk    Body    of    the    Utekus 
(Adeno-caucinoma) 

The  symptoms  are  the  chi(»f  guide  to  a  diagnosis  of  cancer  of 
the  body  of  th(»  iittTus.  Bleeding  alternating  with  a  watery  dis- 
charg(\,  occurring  in  a  woman  who  is  past  the  menopause,  and  the 
exclusion  of  fibroids  and  of  cancer  of  the  cervix,  make  cancer  of 
the  body  probable.  Cancer  of  the  tody  of  the  uterus  is  more  com- 
mon in  nulliparte  than  in  women  who  have  borne  children.  Then" 
is  sometimes  a  charactc^ristic  odor  to  the  uterine  discharge  in  cancer. 
It  can  not  Ik*  descrilM'd,  however*.  A  recurrent  pain,  similar  to 
laI)or  pains,  coming  on  n^gular  days  and  of  several  hours'  duration, 
the  so-called  Simpson  symptom,  has  lx»en  described  as  character- 
istic of  cancel-  of  tlu^  ])0(ly.  This  sort  of  pain  is  found  also  in  myoma 
of  submucous  evolution  and  must  \yo  interpreted  as  the  result  of 
the  stinnihition  of  tlie  utiM'us  by  a  fon^ign  Ixxly  which  it  is  tr}dng 
to  expel.  There  is  nothing  characteristic  in  the  uterine  discharge 
of  cancer  to  distinguish  it  from  the  discharge  from  myoma,  except 


CANCER  OF  THE  TTERUS 


277 


tlmt  on  inierfjst'opif  (*\nmination  canrcr  ciciucnts  may  fn*  dis- 
tinguinlici!  in  it.  A  utfriuc  ilischar^e  oci'urmig  m  a  woiuan  pa.^t 
forty  sljoiili]  Icarl  to  an  invt'sti^aticin. 

So,  also,  palpation  gives  no  chiU'at-ttTistir  iV'rliiig.  Ttiore  should 
Ix^  slight  enlargement  of  the  body;  there  may  be  tendenie^.  In 
patients  with  very  thin  or  lax  abdominal  walls  it  ma}^  Ijt*  posHiible 
in  exceptional  causes  to  make*  out  a  localized  tumor  in  the  Ixxly 
of  the  uterus.     This  ii^  unusual. 

The  diagnosis  is  established  by  exploration  of  the  cavity  of  the 
uterus,  first  with  the  sound  and  then  with  the  curette  forceps  or 
the  finger.  The  sound  will  tletect  friable  tissue,  the  eurt»tte  foret^ps 
will  remove  it  for  microscopic  examination.  Every  part,  of  the 
utc^rine  ca\Hty  must  be  reached  by  the  curette,  as  the  initial  lesion 
may  Ix*  very  small  and  easily  overlookefl. 

The  curette  forceps  are  espfTially  valuable  in  this  case,  for  they 
pinch  off  and  remove  tiasue  without  tearing  it  to  picxtc^s.  The  finger 
introduced  to  the  fundus  can  recognize  beginning  cancer  of  the 
mucous  membrane. 

In  order  to  examine  with  the  finger  ether  must  he  mlministered 
arul  the  cervix  dilates!  with  steel  branched  dilators  and  large  Hegar 
dilators,  A  metho*!  devised  by  IL  A,  Kelly,  consisting  of  an  an- 
t<»rinr  coIjMitomy  antl  ilivision  of  the  ant(*rior  wall  of  the  eenix 
(sec  page  94),  is  of  value  often  in  (exploring  the  interior  of  the 
uterus.  As  in  the  other  forms  of  uterine  cancer^  the  microscojx*  is 
the  means  of  a  sure  iliagnosis. 

Dijferenlial  Biagrwsi^  of  Cancer  of  the  Body  of  the  Uterus 


Tlie  tlifferc^ntial  tliagnosis  is  a  matter  of  the  mien^scopic  exami- 
nation. The  physician  should  remexnlx?r  that  sarcoma  of  the  endo- 
metrium, necrotic  myoma,  mucous  poI\^i,  the  protlucts  of  eonc(*|>- 
tion,  or  hydatidifomi  moles  may  Ix'  found  in  the  uterine  cavity, 
Thf*  characteristics  of  cancer  of  the  fundus  have  Ix^en  referretl  to 
alreaily  i  page  269). 

fii^fore  leaving  the  sul)ject  of  uterine  cancer  it  is  well  to  draw  at- 
tention to  the  great  difiieulty  often  experiencetl  in  determining 
whether  a  thickening  in  the*  broa<l  figaments  is  of  inflammatory  or 
of  cancerous  origin,  It  is  w(41  to  Ix^ar  in  mind  that  most  tliicken- 
iiigp  are  the  result  of  oltl  |x*lvic  inflammation.    Cancer  may  super- 


278     DUGNOSLS  OF  M.\LIGNANT  DISEASES  OF  THE  UTERUS 

vcne,  however,  and  then  it  may  be  assunKMl  that  all  of  the  indura- 
tion is  ihie  to  the  cancerous  infiltration.  The  history  of  the  case 
Ls  of  some  assistance  in  differentiating  the  two. 

If  there  has  be(*n  jx^Kdc  inflammatory  disease,  it  will  be  shown 
by  a  history  of  difficult  and  infected  labors  and  abortions  and  a 
history  of  old  attacks  of  "inflammation  of  the  bowels."  We  have 
seen  what  are  the  usual  routes  of  infection  of  the  surrounding 
tissues  in  the  different  forms  of  uterine  cancer,  both  as  to  the  cellu- 
lar tissue  and  the  glands.  Then  we  know  that  cancer  of  the  body 
seldom  extends  to  the  broad  ligaments  and  to  the  lymphatic  glands 
except  in  the  late  stages  of  long  neglected  cases,  whereas  cancer  of 
the  cer\acal  canal  extends  to  the  surrounding  tissues  relatively 
early. 

THE  DIAGNOSIS  OF  SARCOMA  OF  THE  UTERUS 

Sarcoma  of  the  uterus  is  of  very  rare  occurrence.  It  is  most 
often  found  between  the  ages  of  forty  and  sixty.  W.  A.  Edwanls 
{Amer.  Jour.  Med.  ScL,  July,  1909)  has  recently  collected  16  cases 
of  sarcoma  of  the  uterus  in  children  who  were  fifteen  years  of  age 
or  younger.  It  forms  about  4.8  per  cent  of  all  malignant  growths 
and  2  per  cent  of  all  uterine  tumors.  (E.  Hurdon,  Kelly  and  Noble, 
"  Gynecolog}'  and  Abdominal  Surgery,"  Vol.  I.,  p.  151.)  It  is  a 
disease  originating  from  connective-tissue  elements  as  contrasted 
with  epithelial  elements  from  which  carcinoma  arises.  There  is  to 
be  noted  in  sarcoma  not  only  a  numerical  increase  in  the  number 
of  cell  (elements,  a  hyperplasia,  but  also  a  change  in  the  original 
typ(»,  h(»teroplasia.  The  small  round  or  spindle  cells  acquire  large 
nuclei,  many  times  larger  than  the  nuclei  of  the  original  cells  of 
the  connective*  tissu(\  There  is  great  proliferation  of  the  cells 
into  the  surrounding  tissu(*s  and  later  metastases  by  the  blood- 
vessels to  distant  organs.  The  prolif(»ration  is  not  everywhere 
uniform:  largc^r  and  smalltT  cells  lie  together,  so  that  the  distin- 
guishing characteristics  of  sarcoma  are  the  change  in  the  type  of 
the  cells  and  the  dissimilarity  of  their  arrangement.  In  sarcoma 
th(»  tumor  i)arenchyma  is  richly  vascularized,  carrying  its  owii 
blood  supply;  whereas  in  cancer  tlu^  blood-vessels  are  containeil 
only  in  fibrous  s(»pta.  Therefore  sarcomata  arc  full  of  blood  and 
an^  not  so  apt  to  Ik*  found  in  a  deg(»nerat<*d  condition. 


SARCOMA  OF  THE  CT^ERUS 


279 


Three  varietirs  are  jvcogiiiztHl  by  imtliologi.sts:  si)in<llt^-cclled 
sarcoma;  giant-celletl  sarroiiia;  and  suiaJl  muiuUcelletl  sarcoma. 
The  last  is  the  mo!?t  difficult  to  diapio.se  mt(Tosco|>ieal]y,  csjH'cially 
if  only  small  pieces  are  funiishe*!  from  a  eurettjiig.  The  disease 
may  originate  in  any  of  the  struetvires  of  the  uterus  where  Cini^ 
nective  tissue  is  found,  in  the  mterglandular  connective  tissue  of 


Tm,  113.— Roimd*€elled  Sarcoma  of  the  Body  of  the  Ut-erus.     (CuUon.) 

endometrium,  in  the  connective  tissue  of  the  myometrium, 
^T  about  the  blood-vessels.  One  of  tiie  most  frequent  si-ats  is  a 
preexisting  myoma  of  submucous  or  interstitial  development; 
the  next  most  fre(]uent  is  the  body  of  the  uterus,  and  the  least 
frequent  is  the  cervLx. 

In  mrcoma  of  the  body  of  the  uterus j  if  the  disease  originates  in 
endometrium,  there  is  a  diffuse  thickening  and  infiltration  of 
Ihe  endometrium,  accompanied  often  by  more  or  less  definitely 


280     DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

circumscril)ed  outgrowths.  The  growth  is  soft  and  friable,  con- 
sisting of  a  homogeneous  brain-likt^  substance  very  well  vascular- 
ized. 

Sarconiu  of  the  muscular  wall  usually  occurs  as  a  circumscribed, 
nodular  growth  and  rarely  as  a  diffuse  infiltration. 

Sarcoma  of  tlie  cervix  occurs  in  two  forms,  a  polypoid  tumor  of 
soft  consistency  and  smooth  surface,  attached  by  a  broad  base, 
or  a  tumor  made  up  of  many  little  blebs  of  tissue  of  different  sizes, 
racemose  in  character,  something  like  a  hydatidiform  mole  or  the 
grape-like  vaginal  sarcomata  of  infants.  These  latter  tumors  are 
sometimes  called  myxosarcomata. 

The  diagnosis  of  sarcoma  can  not  be  made  without  the  aid  of  the 
microscope.  Metastases  by  way  of  the  blood  current  occur  in 
about  a  fourth  of  the  cases  of  sarcoma  of  the  endometrium,  accord- 
ing to  G.  \Mnter.  They  are  in  the  lungs,  intestine,  and  peritoneum. 
The  lymph  glands  are  very  seldom  involved.  Metastases  from 
sarcomata  of  the  uterine  wall  or  myomata  invaded  by  sarcoma 
are  more  frequent,  being  found  in  the  lungs,  liver,  and  intestine. 


THE    DIAGNOSIS   OF    MALIGNANT  CHORIOEPITHELIOMA 

Sanger  in  1889  (M.  Sanger, ''Ueber  Deciduome,"  Cen^rott./.  Gyn,, 
1889,  Bd.  13,  p.  132)  reported  a  case  of  deciduosarcoma:  a  tumor 
developing  in  the  uterine  cavity  after  pregnancy  and  followed  by 
metastases  to  distant  organs.  Soon  other  observ(^rs  reported 
similar  tumors  under  the  names,  Deciduoma  malignum,  Deciduo- 
sarcoma, Placentoma,  Syncytioma  malignum,  Malignant  hydatidi- 
form mole,  or  other  names. 

Marchand  (F.  Marchand,  **Ueber  das  maligne  Chorioepitheliom 
nebvSt  Mittheilung  von  zwei  neuen  Fiillen,''  Zeitschr,f  Geb.  u,  Gyn.^ 
Bd.  39,  p.  173)  in  1895  and  the  following  years  showed  that  the 
tumor  originates  in  the  epithelial  ct^lls  covering  the  chorionic  villi, 
and  is  of  a  fetal  rather  than  a  maternal  (decidual)  source,  hence 
the  name  Chorioepithelioma,  which  has  since  been  generally 
adopted  by  the  many  authors  reporting  cases. 

The  disease  consists  of  a  tumor  without  sharply  defined  border 
developing  in  the  mucous  nK^nbranc^  of  the  body  of  the  uterus 
(very  rarely  in  the  Fallopian  tulx^  or  the  vagina)  and  invading  the 


MALIGNANT  GIIORIOEPITHELIOMA 


281 


mucoiis  8tnjrture.  It  is  ilark  iv\]  hi  color,  of  soft  consii^nicy, 
and  abundantly  .suppliinl  with  blocML  It  has  a,  tcinlcncy  to  Ixtouil* 
gangrenous  uml  in  timt  rase  lias  a  foul  uihn-. 

The*  s?urfat*o  is  apt  to  Ik*  unevenly  loljulatrd.  On  rross  section, 
the  Btructure  is  seen  niicrosnopieally  to  In*  made  uj)  of  fibrtJiis 
septa  and  large  spaces  filled  with  extra vasat(*d,  elottefl  blood,  or 
placental  tissue.  Larger  or  smaller  nodules  are  to  b*  scc?n  in  tlie 
uterine  muscle,  which  iM^eomes  often  very  thin  when  the  disease 
has  nearly  penetrated  to  the  iMTitoneiun.     Tlit*  nit*tastases  show 


Fui.   1 1  L — Choriix^ijithdiurnu  nf  the  F*ostcrior  Wall  of  ttiu  rftTus.      (Winter.) 


the  same  characteristics.  In  the  later  stages  thcTe  are  numerous 
m(4;istasc^s  from  the  growth,  not  only  in  the  neighl>orhoo<l  of  th(^ 
uttTUs  but  in  distant  f»rgans,  most  eommonly  in  the  lungs,  and  the 
disease  proves  fatal  in  a  majority  of  cases. 

Th(»  disease  never  oeeurs  except  after  pregnancy,  "most  often 
after  hydatidiform  mole  and  alxirtion.  It  generally  occurs  oidy 
a  few  wet»ks  after  tlie  pregnancy,  but  may  h)e  delayer!  several 
montlis. 

The  usual  chain  of  happenings  in  the  case  of  chorioe|)ithelioma 


282     BUGNaSIS  OF  MALIGNANT  D1SE.\SES  OF  THE  tITERrS 

18  as  follows:  hemorrlmges  occuiTuig  after  abortion  or  tlie  delivery ' 
of  a  hyflaticlifonii  inol(%  curetting  anil  the  removal  of  tissue  without 
stopping  tlio  blerilijig^  c|uirkly  tleveloping  aneraia,  and  signs  of 
metastases  in  the  king.^  (puiti,  henioptymH,  anil  rise  of  temperature). 
It  is  plain  that  prompt  hysterectomy  is  indicated  in  order  to  save 
life.  In  exeeptiona!  eases  tlie  o\ami  which  has  growia  a  chorioe- 
pitlielioma  is  (a)  m  the  Fallopian  tube  and  not  in  the  uterus,  and 
in  still  rarer  cases  (b)  in  the  wall  of  the  vagina. 

These  cases  are  calkn:!  Ectopic  malignnnt  chorioepithelioma.  In 
the  first.^  {a)  the  symptoms  are  those  of  extra-uterine  pregnancy, 
and  in  the  second,  (b)  they  are  th<^  mme  as  in  the  uterine  variety. 
The  primary  disease  in  the  vagina  being  more  accessible  to  sight 


Fig.  115. — Metastasis  m   tlie   Vagina  from  Chorioepithelioma  of  the  Uterus. 

(Winter.) 

and  touch,  the  diagnosis  should  be  made  more  promptly  than 
w^hcn  it  is  in  the  uterus. 

According  to  J,  Veit  ("Das  maligne  Chorioepitheliom/'  Hand- 
biich  d,  Gyn.,  il  Auf.,  Bd.  3,  1908)  microscopic  study  of  the  tissues 
shows  that  syneytiuin,  Langhans'  layer,  and  connective  tissue  of 
the  chorion,  when  all  present  in  the  same  case,  are  fomul  primarily 
in  the  veins  of  a  uterus  that  has  hvim  prcgnantj  and  esjiecially  after 
hydatidifonn  mole.  If  the  epithelial  cells  of  the  chorionic  villus 
proliferate  rapitlly  in  the  veins,  iM^ing  well  nourisheth  thr^  process 
is  malignant.  The  factor  which  determines  the  malignancy  of  the 
growth  is  the  proliferating  power  of  the  ej^ithelial  eeUs  and  not 
the  invasion  of  the  veins  liy  tlie  coTmrxiive  tissue  of  the  chorion. 

If  by  chance  the  proliferating  epithelial  cells  of  the  \iUus  get 


r^^^» 


MALIGNANT  rHORIOEPITHELlOiU 


283 


into  other  tissues  than  the  vdn.s»  as,  for  ioHtaiit*e,  into  the  ix^ri- 
toneum,  the  process  ecases.  A  non-iimligitaiit  form  of  the  iliseast* 
has  lx*en  reported,  aod  at  the  jjresent  time  authorities  are  not 
agreed  as  to  the  rea.s<3n  for  the  two  forms  or  as  to  tlieir  ditTer- 
entiation  before  the  six^cimen  reaches  the  pathologit-al  la}x)raiory, 
therefore  it  iB  safe  to  assume  that  every  case  of  ehoriof*pithclionia 
is  malignant  and  treat  it  accordingly. 


Diagnosis 

The  diagnosis  dr|>end8  on  the  api)areitt  rccurrenro  of  a  placental 
polyp  after  abortion  or  a  hydatidiform  mole,  with  hemorrhage, 
and  a  watery^  foul  tUschargi\  Rapidly  developing  anemia  under 
such  conditions  is  a  8us[>icious  sym[jtom,  a.s  tiie  anemia  dt'velops 
more  rapidly  in  this  than  in  any  known  disease.  Ti.^sue  removed 
by  the  curette  or  curette  forceps  is  submitted  to  microscopic  exam- 
ination. Better  still  the  ei^rvHx  is  dilated  until  the  canal  will  luhuit 
the  phy.sician's  fon^finger  ant^l  (hgital  exploration  demonstrates 
the  prepuce  of  a  soft  tumor. 

The  tissue  of  a  chorioeijithohoma  is  much  more  friable  and 
softer  than  that  of  a  i)Iacental  or  otlier  polypus.  The  uterus  is 
found  to  b*^  srimewhat  rnlarged  when  the  bimanual  touch  is  prac- 
ticed.    In  most  eases  it  is  not  sensitive. 

In  cases  of  hy<latidiform  mole  the  physician  should  keep  his 
patient  under  obst^rv^ation  for  several  weeks  after  the  mole  has 
Invn  delivered  and  should  Ix^ar  in  mind  th«'  fiossibility  of  the 
development  of  a  ehorioepithelioma.  Early  removal  of  a  chorioepi- 
thelioma  is  attendetl  by  lasting  cure. 


CH.\PTER  XMI 
THE  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

Anatomy  and  age  changes,  p.  284. 

Anomalies,  p.  285.     Atrophy,  p.  285. 

Displacements,  p.  286:  Undescended  ovary,  p.  286.  Prolapse  of  the 
ovary,  p.  286.     Hernia  of  the  ovan%  p.  288. 

Inflammations  (Ovaritis),  p.  288:  Acute  ovaritis,  p.  288;  Diagnosis  of 
acute  overitis,  p.  288.  Chronic  ovaritis,  p.  290.  Diagnosis  of  chronic 
ovaritis,  p.  290. 

Tumors  of  the  ovary,  p.  291 :  Modes  of  development,  p.  292.  Classifica- 
tion, p.  293.  Malignancy,  p.  293.  Etiology  and  symptoms,  p^  298.  Di- 
agnosis in  general,  p.  295.  Diagnosis  of  small  ovarian  tumors,  p.  296; 
Differential  diagnosis  of  small  ovarian  tumors,  p.  296.  Diagnosis  of  large 
ovarian  tumors,  p.  301;  Differential  diagnosis  of  laige  ovarian  tumors, 
p.  305.     Tables,  pp.  308,  309. 

Complications  of  ovarian  tumors,  p.  315:  1.  Adhesions  and  incarceration, 
p.  315.  2.  Intraligamentous  development,  p.  316.  3.  Torsion  of  the  pedicle, 
p.  317.  4.  Infection  and  suppuration,  p.  318.  5.  D^enerative  processes, 
including  malignancy,  p.  318.  6.  Rupture,  p.  319.  7.  Association  with 
pregnancy,  p.  320. 

Diagnosis  of  the  different  pathological  varieties  of  ovarian  tumors,  p.  321. 

ANATOMY  AND  AGE  CHANGES 

At  birth  the  ovaiy  is  an  elongated  body,  lying  parallel  with  the 
Fallopian  tube  and  resembling  in  shape  a  flattened  cucumber. 
(See  Fig.  117.)  Its  surface  is  smooth,  its  bonlers  may  be  crenate, 
and  it  may  have  a  longitudinal  furrow.  At  puberty  it  has  become 
transforuK^d  into  a  smooth  olive-shaped  gland,  grasdsh-pink  in 
color,  If  inche.'-  long  (4  cm.),  J  to  1  inch  broad  (2  to  2.5  cm.),  and 
J  inch  thick  (1  to  1.5  cm.)  and  weighing  about  2  drams  (6  grams). 

From  pulx^rty  to  the  mc^nopause  it  maintains  the  same  size  and 
shape,  but  the  smoothness  of  its  surface  is  marred  by  scars,  the 
results  of  rei3eated  lacerations  caused  by  the  rupture  of  the  ripe 
Graafian  follicles.     (See  Fig.  118.) 

After  the  menopause*  the  ovary  shrinks  and  becomes  wrinkled 
and  atroi)hic,  and  at  the  age  of  sc^vi^nty  weighs  about  one  gram. 
(Sec^  Fig.  119.) 

284 


ANOMALIES 


285 


ANOMALIES 

Congenital  ab^eorc  of  iKitli  ovaric.s  is  rair  ami  It^  lissociateil  with 
defective  dcvelo|>nipnt  of  tiio  uterus  and  partial  or  coiii|>lcte  al> 
sence  of  the  vagina.  Ah'^Miec  of  one  ovary  usually  aeeonipanies 
defieiency  of  the  eorresjxinding  half  of  the  uterus  and  tht*  Fallupinn 
lube,  and  aUsenee  or  inisplaeenient  of  the  kidney  on  the  sanu*  side 
of  the  body.  There  is  on  reeoni  no  reliable  tlei>eription  of  a  super- 
numerary^ ovaiy ;  the  lx>di(*s  deseribe^l  as  sucli  being  eoqiora  fibroj^a, 
small  myomata  of  the  o^^arian  liganientj  or  lyai-tially  detachetl  tub<:rs 


^Parorttriumn 


titrftnitij. 


7^ 


nTsT 


UTERUS*! 


jV  ARy 


■>*■ 


i 

Fimbria  tttunca. 
Fra.  116,— The  Ovary  and  Tube  Seen  from  Bcliiiiil.      i  Ht-riU-.) 

of  the  parovarium.  Faulty  growth  of  the  ovary  is  romrnouly 
associatal  with  the  uti^rint-  condition  known  as  infantile  uterus, 
with  rudimentary  uterus. 
Atrophy  of  the  ovaries  oeeurs  normally  at  the  mt^nopause.  They 
become  smaller  and  liardii-  and  the  oophoron  (the  egg-h<*aring 
zone  on  the  outside  of  the  ovary)  is  transformed  into  a  layer  uf 
d(*ns4_»  fibrous  tissu*'.  LminlUm  atrophf/  is  a  shi'inkfvge  in  the  sizr 
of  the  ovary  oceurringsomrtimi^s  in  wnrnen  wln>  have  nursi'd  their 
children  for  a  long  tinH\  Ovarian  atrophy  has  Ijeen  reportc^l  hi 
the  exanthemata,  myxedema.  markiHl  aiK^rriia^  and  in  diaf)etes. 
It  is  supposed  to  occur  in  connection  with  rajjidly  acquired  obesity. 


286 


DUGNOem  OF  DISEASES  OF  THE  OVARIES 


At  all  events  young  women  who  have  suddenly  become  fat  fre- 
quently suffer  with  amenorrhea.  On  account  of  the  increase  in 
fat  in  the  alxlominal  walls  it  is  not  easy  to  determine  a  decrea^  in 
the  size  of  the  ovaries  in  these  patients,  but  in  certain  cases  atrophy 
has  been  definitely  made  out. 

In  1&(J0  I  o|x»ncMl  the  abdomeix  in  a  case  of  abeolute  amenorrhea 
of  eight  months'  duration  following  steaming  of  the  uterine  cavity 
at  the  hands  of  another  practitioner.  The  woman  was  twenty- 
eight  years  old,  the  mother  of  two  children.  The  ovaries  were 
found  to  be  partially  atrophied  as  well  as  the  uterus. 

BISPLACEMENTS  OF  THE  OVARY 

(a)  lTndef?cendetl  ovary,  (6)  Prolapse  of  the  ovary,  (c)  Hernia  of 
the  ovary. 

(a)  Undescended  Ovary. — The  ovaries  arc  in  close  relation  with 
the  kiilocys  in  the  embryo  and  they  gradually  move  downward 


Fia*  117. — Ut^ru^  TtibeSi  fmd  Ovaries  of  an  Infant  Cue  Mouth  Old. 

to  the  pehi??,  at  birth  lying  on  the  psoas  magnus  muscle  in  close 
relation  with  the  hitomal  alxlorninal  ring.  They  get  to  their 
normal  situation  in  the  adult  soon  after  birth.  It  may  happen  in 
very  rare  instances  that  an  ovarj^  may  n^niain  in  the  neighborhood 
of  the  kidney  and  may  retain  its  infantile  shajx*.  If  it  is  the  right 
ovary  that  has  faik>tl  to  tlescend  the  cecum  also  generally  remains 
high  up,  in  its  fetal  position. 

(6)  Prolapse  of  the  ovary  may  occur  when  from  repeated  preg- 


E 


1 


DISPLACEMENTS  OF  THE  OVARY 


287 


nancies  the  ovarian  and  broml  ligaments  have  been  stTetched  and 
suteequently  not  properly  involuted,  jx^niiitting  the  ovary  to  sag 
back  into  Douglas'  cul-ile-sac.  Also  when  an  ovaiy  is  enlai-getl 
for  any  reason  and  thu^  gravitates  of  iti^  own  weight  to  the  pelvic 
fl(X)r.  Misplacements  of  the  uterus,  such  as  retroversiou  and 
rt^troflexion,  are  commonly  a.^sociated  with  prolapse  of  the  ovaries. 
Prola]>sed  ovarien  may  be  tender  to  touch,  when  we  may  asjiumc 
that  they  are  the  seat  of  inflammation,  oranti.'i.     In  this  event 


I 

I 


t/tero-  Qv\r  tA  r 


Tube 


BrnAd  tl^AtTieri 


Fig.  118. — Ovary  urnJ  Tube  of  a  Wotuan  liuring  Sexual  Maturity. 

they  may  cause  suffering  when  pressed  on  during  the  act  of  defeca- 
tion, es{j€*cially  the  left  ovary^  or  during  coitus.  The  diagnosis  is 
established  by  the  bimanual  touch.  Absence  of  the  ovary  in  its 
normal  situation  and  its  presence  at  the  base  of  the  broa^l  ligament 
as  determined  by  recta!  touch  arc  the  diagnostic  [joints.  It  is 
often  difficult  to  differentiate  a  prolap^Ml  «>vary  from  a  small 
scybalous  mass  in  the  rectum.    In  oriler  to  do  this  successfully, 


288  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

thoroughly  cleanse  the  rectum  by  enema,  and  examine  a  second 
time.  In  some  cases  it  is  well  to  use  the  proctoscope  to  be  sure 
that  the  upper  rectum  is  free.  If  the  ovary  is  tender  distinguish- 
ing it  is  easier. 

(c)  Hernia  of  the  ovary  is  comparatively  rare  in  adults  but  occurs 
not  infrequently  in  infants  under  a  year  and  a  half  old.  It  may 
occupy  a  hernial  sac  either  alone  or  accompanied  by  its  Fallopian 
tube.  Ovarian  hernia  is  more  apt  to  occur  as  an  inguinal  than 
as  a  femoral  hernia.  Congenital  hernia  of  the  ovary  is  ver}' 
rare,  but  it  may  occur  in  the  early  months  of  infancy  because 
the  ovaries  and  tubes  at  this  time  normally  lie  in  close  prox- 
imity to  the  abdominal  ends  of  the  inguinal  canals.  (See  Fig. 
206.)  Many  cases  reported  as  heniia  of  the  ovary  are  hydroceles 
of  the  canal  of  Nuck.  Hernia  of  the  ovary  may  occur  at  any 
age  up  to  the  seventy-third  year.  The  diagnosis  can  be  made 
definitely  only  by  operation.  It  is  difficult  to  be  sure  of  the 
alisence  of  the  ovary  on  one  side.  A  hernia — preferably  an 
inguinal  hernia — ha\'ing  a  tender  body  in  it,  while  at  the  same 
time  the  ovary  on  that  side  can  not  be  palpated  in  its  normal 
situation,  makes  a  probable  diagnosis. 


INFLAMMATIONS  OF  THE  OVARY 

Ovaritis  may  be  acute  or  chronic.  The  acute  form  occurs  in 
infections  following  labor  or  abortion,  gonorrhea,  typhoid  fever, 
miliary  tuberculosis,  the  acute  exanthemata,  or  numips.  The 
ovary  is  erilarge<]  and  congested,  the  oophoron  or  the  paroophoron 
Ixiing  involved,  or  both.  The  tissues  are  infiltrated  mth  serum, 
leuco(*ytes  which  have  (»scap(Ml  from  the  blood-vessels,  and  some- 
times with  blood.  If  there  is  a  large  colk^ction  of  blood,  a  hema- 
toma of  the  ovary  is  formed.  Absces.s  of  the  ovary  may  be  the  n»sult 
of  sc^vere  grad(»s  of  inflammation  and  a  tumor  which  reaches  the 
size  of  an  egg  may  ev(*ntuate.  There  an*  apt  to  be  adhesions  to 
th(»  surrounding  structun^s,  such  as  tlu^  Fallopian  tubes  and  in- 
testines. The  absct^ss  may  niptun*  into  the  intestine,  bladder,  or 
vagina.  It  has  been  known  in  ran*  cases  to  lireak  into  the  general 
peritoneal  cavity,  causing  fatal  peritonitis. 

Diagnosis  of  Acute  Ovaritis. — Pelvic  pain  aggravated  by  move- 


INFLAMMATIONS  OF  THE  OV.UtY 


289 


Bnt  of  the  body  or  by  defecation,  and  tenderness  on  pres8ure  in 
the  ovarian  regions,  are  characteristic  of  a  niild  attack  of  ovaritis. 
Chills  and  marked  elt^vation  of  the  Ixniy  temperature  are  to  be 
expected  if  suppuration  occurs.  If  there  is  peritonitis  of  any 
extent  there  will  be  rigitlity  of  the  abionien  and  a  rapid  and  small 
pulse  and  increased  pain.  If  it  is  [X)ssible  to  palpate  the  ovary 
it  will  be  found  enlarged  and  ex([uisitrly  tender.  Commonly  the 
rigidity  of  the  alxlorainal  walls  prevents  exact  differentiation  of 
the  structures  involveil  An  abscess  is  usually  fixeiJ  in  a  mass  of 
exudate.     Fluctuation  may  be  nmdo  out  by  rectal  palpation,  but 


yy 


Fjg.    1  UJ.— Senile  Ovary  and  Tube* 

often  the  wall  of  the  aliscess  is  so  tiiiek  that  this  is  impossible. 
In  the  case  of  acute  ovaritis  it  is  impossible  to  distinguish  exactly 
between  ovaritis  and  salpingitis.  If  the  disease  is  right-siiled  we 
must,  if  possible,  eliminate  appendicitis.  The  history  of  the  onset 
is  the  important  jjoiot  in  distinguishing  the  two.  Acute  pelvic 
I  inflammation  is  generally  preceded  by  a  vaginal  discharge  or  other 
uterine  symptoms  such  as  dysmenorrhea,  whereas  in  appentlicitls 
there  is  a  histor>'  of  digestive  disturbances,  such  ns  diajrhea  alter- 
nating with  constipation,  or  nf  previous  attacks  of  pam  in  the 
right  lower  abdomen.  The  pain  of  pehic  disease  is  dull  and  steady 
and  is  situated  deep  in  the  pehds,  pressure  over  Poupart's  ligament 
19 


290 


DUGNOSIS  OF  DISE.\SES  OF  THE  OVARIES 


occasioning  great  suffering.  The  pain  of  appendicitis  is  sharp 
and  colicky  and  is  higher  in  the  abdomen  and  is  more  diffused. 

If  the  appendix  hapjx^ns  to  be  in  the  pehis  or  if  there  is  much 
I)eritonitis  it  is  impossible  to  distinguish  the  two  affections. 

Chronic  ovaritis  may  follow  an  acute  ovaritis  or  it  may  originate 
in  an  infection  of  the  uterus,  especially  in  gonorrhea.  It  is  also 
found  in  the  presence*  of  fibromyomata  and  krge  ovarian  tumors 
of  the  opposite  side,  although  the  disease  is  generally  bilateral. 

The  oophoron  is  usually  affected,  the  Graafian  follicles  often  be- 
coming enlarged  and  causing  atrophy  of  the  stroma  because  of  their 
size.  Such  a  condition  is  called  small  cystic  degeneration.  In  certain 
cases  the  entire  cortical  region  of  the  ovary  (oophoron)  is  trans- 
fonned  into  little  cysts  containing  a  clear  fluid,  the  ovum  having  dis- 


FiG.  120. — Diagram  Showing   the   Cyst  and   Tumor   Regions   of  the   Ovan*. 

(After  Bland-Sutton.) 

appeared.  Now  and  then  a  few  noiTnal  follicles  may  be  found.  In 
some  cases  of  chronic  ovaritis,  thc^  stroma  and  not  the  follicles  is  in- 
vo1v(h1.  In  the  late  stages  of  this  disease  the  ovary  is  found  small  and 
scirrhotic  with  a  puckered,  uneven  surface,  as  from  many  scars. 

Diagnosis  of  Chronic  Ovaritis. — ^There  is  nothing  pathognomonic 
in  the  symptoms  of  this  disease.  There  is  apt  to  be  pain  in  the 
ovarian  n^gions,  and  scanty  menstruation  if  the  ovarian  stroma 
has  Ix^en  destroyed,  also  dysmenorrhea.  The  ovaries  may  be 
tender  to  th(»  touch;  often  they  an*  not.  The  bimanual  touch  may 
determine  follicular  enlargemc^nt  or  a  nodular  feel.  In  only  ex- 
ceptional ca,s(^s  when  all  th(^  factors  are  favorable,  more  especially 
at  an  examination  under  an  anesthetic,  can  a  small  cirrhotic  ovary 
be  diagnosed. 


OVARIAN  TUMORS  291 


OVARIAN  TUMORS 

We  have  considered  already  certain  states  of  the  ovary  that 
strictly  may  be  classed  as  tuniors,  for  instance,  "small  cystic  de- 
generation'* and  mflammatory  conditions  with  enlargement. 

Let  us  now  take  up  ovarian  tumors  propcT,  counting  as  tumors 
all  enlargements  of  the  ovary  greater  in  size  than  a  hen's  egg,  using 
Pfannenstiers  classification  ba^nl  on  the  origin  of  the  tumor. 
(Veit's  "Handbuch,"  J.  Pfannenstiel,  "Die  Erkrankungen  des 
Ovarium.'') 

A.  Nox-Proliferatixc;  Cys'fs. 

(Follicular  cysts;  Cysts  of  thcj  corpus  luteum.) 

B.  New  Formations. 

I.  Parenchyniatogenmis  Tumors. 

(Tumors  arising    from    germinal   or   follicular  epithelium^ 
or  from  the  ovum.) 
1.  Epith(»lial  New  Formations, 
(a)  Cystoma  serosum  simplex. 
(Simple  cyst.) 


(h)  Cyst  adenoma 


Pseudomucinosum. 

(Multilocular  cysts.) 
Serosum. 

(Papillary  cysts.) 
(r)  Carcinoma. 
2.  Kmbrj'omata. 

(Tumors  springing  from  the  ovum.) 
(a)  Dermoid  cysts. 
(h)  Teratomata. 
II.  Stromatoyenou.s  Tuwors. 

(Tumors  arising  from  the  connc^ctive  tissu<\) 

1.  Fibroma. 

2.  Sarcoma. 

3.  Peri-  and  Endothelioma. 
C.  Mixed  Tumohs. 

(\'arious  coml)inations  of  tlu*  tumor  processes  enumerated.) 

Fig.  120  shows  diaiirammatically  the  dilTerent   portions  of  the 
ovary  affected  by  neoplasms. 


292 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


Modes  of  Development  of  Ovarian  Tumors 

The  accompanying  diagrams  indicate  the  method  of  develop- 
ment of  the  pedicle  of  a  tumor  and  the  arrangement  of  the  peri- 
toneum in  the  case  of  the  normal  ovary,  a  free  ovarian  cyst,  an 
intraligamentous  cyst,  and  an  adherent  ovarian  cyst.  It  is  plain 
that  the  broad  ligament,  the  Fallopian  tube,  the  romid  ligament, 


J^icle. 


'^tube. 


Figs.  121-124. — Four  Diagrams  Sho\ving  the   Method   of  Formation   of  the 
Pedicle  in  the  Different  Sorts  of  Ovarian  Tumors. 

and  th(^  ovarian  ligament  are  inckided  hi  varying  degnx*^  in  the 
pedicle  of  a  large  non-adherent  ovarian  tumor.  Commonly  the 
Fallopian  tube  is  much  elongated  and  spread  over  the  surface  of 
the  tumor,  the  round  ligament  comes  on  to  the  anterior  face  of  the 
tumor,  and  ih(i  ovarian  ligament  is  much  enlarged  and  lengthened. 
In  th(^  ciise  of  tumors  d(»veloping  Ix^twc^en  thi»  layers  of  the  broad 
ligament,  or  of  adherent  ovarian  tumors,  the  conditions  are  as 
shown  in  the  diagram. .  A  j)arovarian  cyst  may  lie  free  in  the 


OVARIAN  TUMORS 


293 


pelvis  atta^jhed  only  by  a  pcHliele  foniicd  from  the  broad  ligament, 
and  it  is  not  unusual  to  fintl  such  a  cyst  as  a  complication  of  a  small 
ovarian  tumor. 

CLASSIFfCATfON 

Ovarian  tumoi*s  have  lx»en  generally  elas.^ifie<i  as  solid  or  rystic, 
and  benign  or  malignant.  As  will  be  seen  from  the  classification 
of  Pfannenstiel,  such  a  division  is  arbitrary  and  many  of  the  tumoi*s 
are  both  solid  and  €>'stic,  and  also  benign  and  malignant.  This  is 
shown  by  careful  microscopic  examination  in  the  pathological 
laboratory  where  a  unilocular  cyst  will  be  found  often  to  have 
small  cysts  in  its  walls,  or  tratecuk^  in  the  cyst  walls,  denoting 
former  subdivisions.  Some  of  the  multilocular  cysts  show  papillary 
masses  in  certain  regions^  while  m  other  placets  small  dermoid  cysts 
may  be  discovered,  and  even  areas  of  cancerous  degeneration. 


Malignancy 

A  benign  turner  is  one  which  tloes  not  tend  to  recur  when  extir- 
pated, 3i>  Well  as  one  which  does  not  implant  itself  elsewhere  or 
mvade  the  tissues. 

A  malignant  tumor  sigiiifies  a  groi^lh  which  tends  to  destroy  life 
by  invasion  of  tlie  surrounding  tissues  as  well  as  one  wiiieh  dis- 
tributes its  elements  by  metastasis  to  other  parts  of  the  body. 

In  a  general  way  one  may  say  that  the  cystadenomata  (multi- 
locular cysts),  the  parovarian  cysts,  the  filiroids  of  the  ovary,  and 
the  dermoid  cysts  are  benign;  the  carcinomatu  and  sarcomata  are 
malignant,  and  the  paj)ilhiry  tumors  are  on  the  border  land.  That 
Ls  to  say,  the  papillary  cystadenomata  tend  to  implant  their  ek^ 
ments  on  the  surn>unding  structure's,  there  to  grow,  but  they  do 
not  invade  the  underlying  structures  as  do  the  carcinouiata  and 
sarcomata. 


Etiology  and  S'iTurroMS 

Ovarian  tumors  are  found  most  often  during  the  time  of  sexual 
activity  in  the  life  of  women,  but  may  occur  at  any  age,     Chiene 


The  eontrolling  factors  are  unkno\\Ti.  The  symptoms  consist, 
during  the  t-arly  ^stages  of  the  gruwih  of  an  ovarian  tumor,  in  the 
usual  syndromata  of  uterine  disease,  and  may  be  of  little  moment 
to  the  patient,  so  that  her  attention  is  not  directal  to  the  pc4vis* 
They  are  menstrual  disturbances, — such  a^  dysnienon*hea,  raenor- 


OVARUN  TUMORS 


295 


rhagia,  or  scanty  menstmatioij, — a  senst*  of  weight  iii  the  i>['hds»  or, 
if  there  is  peritonitis?,  pain,  Wlien  the  tunior  attains  a  considerable 
size,  50  that  it  fiDs  the  peKi.s  or  rises  out  of  it  into  the  abdomen, 
there  are  presmre  sympkun.s.  Th<'so  are  vehiea!  or  rectal  tencn- 
IHQS,  frcKjuent  mieturition,  and  constipation;  in  the  case  of  large 
tumors,  edema  of  the  vulva  and  of  tlie  lower  extremities  caused 
by  pressure  on  tlie  iliac  veinvs:  also  hemorrhoids.  In  rare  cases 
there  have  been  noted  albuminuria  and  suppression  of  uj'ine  from 
hydronephrosis  causcnl  by  pressure  on  the  ureters.  Other  symp- 
toms are  jayndiee  from  occlusion  of  the  bile  ducts,  ascites  from 
pressiu^  obstruction  to  the  portal  system,  dilaltHj  veins  in  the 
skin  of  the  aLKloinen^  the  occurrence  of  the  white  lines  m  the  skin 
kno^^Ti  as  lineie  albicantes,  occasional  umbilical  hernia,  and  de- 
rangements of  digestion  and  tlysi>nea. 

Pain  in  the  aklouKHi  is  a  s}in|)tonj  of  adhesions,  as  a  rule,  and  great 
care  should  l>e  obserw-nl  in  taking  the  aiianmesis  to  get  the  exact  sit- 
uation, character,  and  duration  of  the  pain.  Pain  is  causeil  also  by 
traction  or  torsion  of  the  ijediele  an<l  l>y  secondary  changes  in  the 
contents  of  the  cyst  involving  adhesions  to  the  sensitive  parietal 
peritoneum. 

The  fades  oi^arinn  is  a  pfHniliar  facial  expreasion  that  is  pathog- 
nomonic of  the  late  stage  of  large  ovarian  tumors.  It  consists 
of  an  anxious,  careworn  look;  the  face  is  pale  and  shriveled,  there 
being  wrinkles  m  the  cheeks,  and  it  looks  longer;  the  nostrils  are 
wide  and  the  lips  thin,  the  space  Ix^tween  the  eyelids  and  the  l>ony 
margin  of  tlie  orbits  is  sytike!i.  The  face  iloes  not  have  that 
yellowish  hue  characteristic  of  the  lat^  stages  of  cancer,  nor  yet 
the  full  appearance  of  the  face  of  tlie  pregnant  w^oman. 

There  is  also  to  be  noted  in  large  ovarian  tumors  a  los<  of  tiesh 
over  the  chest  ami  shoultlers,  |»robably  of  a  piece  with  the  atrophy 
of  the  face  just  described 


Diagnosis  in  Gen^eral 


In  considering  the  diagnosis  of  ovai'ian  tumors  it  is  convenient 
to  di\ide  them  into  small  tumors,  tliose  that  lie  wholly  within  the 
pehic  cavity  proj^er,  and  kirtje  iunm*s,  those  that  he  for  the  most 
part  in  the  abdominal  cavity.     We  will  discuss  the  diagnosis  and 


296  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

the  differential  diagnosis  of  each,  then  take  up  the  complications 
of  ovarian  tumors,  and  finally  say  something  of  the  diagnosis  of 
the  different  pathological  varieties  of  tumors,  as  far  as  they  can  be 
distinguished  without  operation. 

The  important  factor  in  the  diagnosis  of  all  ovarian  tumors 
is  to  determine  the  relation  of  the  tumor  to  the  uterus. 

If  it  can  be  shown  that  moving  the  tumor  moves  the  uterus,  or, 
conversely,  that  changing  the  position  of  the  uterus  moves  the 
tumor,  there  is  a  probability  that  the  tumor  is  ovarian.  On  ac- 
count of  adhesions  and  intraligamentous  development,  all  ovarian 
tumors  are  not  movable.  The  tumors  of  medium  size,  those  that 
have  risen  out  of  the  pelvis  but  have  not  yet  distended  the  ab- 
dominal walls  to  excessive  dc^gree,  are  easiest  to  palpate  with 
reference  to  their  connection  with  the  uterus.  To  perform  the 
palpation  to  the  best  advantage,  use  is  made  of  the  bimanual 
vagino-abdominal  touch. 

With  the  forefinger  against  the  cervix,  push  the  tumor  in  the  abdo- 
men or  pelvis  to  one  side  with  a  quick  movement  of  the  hand  on  the 
abdomen.  At  the  same  moment  the  cervix  will  be  felt  to  move  be- 
cause of  the  pull  on  the  pedicle  of  the  tumor.  Sometimes,  but  not 
often,  a  quick  push  on  the  uterus  by  the  finger  in  the  vagina  will  be 
transmitted  to  the  tumor,  as  detected  by  the  hand  on  the  abdomen. 

To  palpate  the  pedicle  the  cervix  is  grasped  by  a  double  tenacu- 
lum held  by  an  assistant  while  the  physician  practices  the  bimanual 
recto-abdominal  touch,  with  two  fingers  in  the  rectum.  (See  Fig. 
126,  page  301.) 

In  this  way  it  is  possible  sometimes  to  get  a  good  idea  of  the 
situation,  size,  and  length  of  the  pedicle  of  a  tumor.  As  pointed 
out  by  John  A.  Sampson  ("Surgery,  Gynecology  and  Obstetrics," 
1907,  Vol.  IV.,  p.  685),  traction  on  thcj  pedicle  of  an  ovarian  tumor 
causes  pain.  Also  twisting  of  the  pedicle,  as  determined  by  opera- 
tions performed  on  patients  by  the  aid  of  local  anesthesia,  causes 
pain  which  is  referred  to  the  pelvis  on  the  side  on  which  the  pedicle 
is  situated. 

Diagnosis  of  Small  Ovarian  Tumors 

Those  tumors,  which  lie  entirely  within  the  cavity  of  the  true 
pelvis,  are  diagnosed  by  the  bimanual  touch,  both  vagino-abdominal 


SMALL  OVARIAN  TUMORS 


297 


and  rectoaMoniinal.  In  the  case  of  the  small  tumor  it  is  diffifult 
to  make  out  the  eharacteristic^  of  the  pedicle.  One  lietermines 
this  in  8ome  ca.ses  a«  de,serilx'<i  al)ove.  We  try  to  aseerlain  the 
ixjmtion,  size,  form,  and  density  of  any  given  pelvic  tumor;  tht^n 
it,s  relation  to  the  utenis.  If  tlie  tumor  is  small  there  i*s  a  likeliliond 
that  the  uterus  can  be  placed  and  its  size  ami  shape  defined  by 
touch.  In  the  larger  tumors,  those  filling  the  pelvis,  such  palpa- 
tion is  difficult  or  impossible.  In  thi.s  event  the  sound  must  be 
passed  to  determine  the  location  and  relative  size  of  the  uterus. 
As  a  rule,  ovarian  tumors  are  round.  This  is  always  the  ease  with 
the  cysts,  the  solid  tumors  \wmg  generally,  but  not  invariably, 
round,  A  fluctuating  consistency  can  be  ma^le  out  in  most  cases 
of  cysts,  A  small-size<l  ovarian  cyst  is  to  be  looked  for  in  the 
situation  of  the  ovary,  and  is  moval>le  (rarely  a<!lierent) ;  an  intra- 
ligamentous cyst  lies  to  one  side  and  behind  the  uterus,  and  is 
inunovable,  A  cyst  may  lie  in  front  of  the  uterus,  rarely,  and,  of 
course,  there  nmy  be  two  ovarian  tumors,  one  on  each  side. 

Differentiaf  Diagnos^^is  of  Small  Omrian  Tunwrs 

We  must  rule  out.: 

1.  Ovaritis, 

2.  Subperitoneal  fibroid. 

3.  Parovarian  cyst. 

4.  Hydrosalpinx,  hematosalpinx^  and  pyosalpinx, 

5.  Encapsulated  peritonitis,  or  inflammatory  exudate. 

6.  Echinococcus  cyst. 

7.  Extra-uterine  pregnancy. 

8.  Early  normal  pregnancy,  or  cornual  pregnancy. 

9.  Distended  m*inarv  bladder. 


I.  Ovaritis. — Tumors  of  the  chronic  form  of  ovaritis  are  seldom 
larger  than  a  pigeon's  egg,  but  the  acute  form  resulting  in  abs<.'ess 
may  be  of  considerable  size.  Here  there  is  fever,  and  the  tumor  is 
of  recent  occurrence,  an  acute  affair.  The  tumor  is  tenrler,  and 
there  is  pelvic  peritonitis  in  varying  degrc^ss  of  intensity  as  evi- 
denced by  rigidity  of  the  abdominal  walls.  Also  there  is  generally 
a  history  of  infection. 

3.  Subperitoneal  Fibroid.— The  differentiation  in  this  case  is  often 


298  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

a  difficult  matter  and  depends  entin^ly  on  the  findings  from  palpa- 
tion. The  consistency  of  an  ovarian  cyst  is  softer  than  that  of  a 
subserous  fibroid.  As  a  rule,  the  fibroid  is  more  intimately  allied 
vnth  the  utc^rus,  and  in  many  cases  the  pedicle  is  short  and  thick 
or  the  growth  is  sessile.  It  helps  in  the  diagnosis  if  other  fibroid 
nodules  can  be  distinguished  in  the  substance  of  the  uterus,  for 
fibroids  are  apt  to  be  multiple.  The  coexistence  of  ovarian  cyst 
and  fibroid  is  not  an  uncommon  occurrence. 

In  the  case  of  an  irUerstitml  fibroid  the  uterus  should  be  enlarged 
and  menorrhagia  is  apt  to  he  a  symptom ;  the  passage  of  the  sound 
will  show  an  increased  depth  of  the  uterine  cavity. 

If,  by  any  chance,  both  normal-sized  ovaries  can  be  palpatcxl,  the 
tumor  is  a  uterine  fibroid. 

3.  Parovarian  Cyst. — Parovarian  cysts  are  generally  relatively 
small  in  size,  therefore  they  are  put  here.  They  may  be  large, 
however.  The  cyst  arises  from  the  epoophoron,  is  generally  uni- 
locular, and  has  a  thin  wall,  with  clear  serous  contents.  It  is  situ- 
ated between  the  tube  and  ovar>'  and  is  intra-ligamentous  in  growih; 
therefore,  when  the  cyst  has  developed  the  tube  is  on  its  upper 
surface  and  the  ovary  Ix^low  it.  In  extremely  rare  cases  the  ovarj^ 
may  be  palpated  by  the  fing(T  in  the  vagina  on  the  under  surface 
of  the  cyst.  As  a  rule,  the  differential  diagnosis  can  not  be 
made. 

4.  Hydrosalpinx,  Hematosalpinx,  and  Pyosalpinx. — ^The  accumu- 
lation of  serous  fluid,  blood,  or  pus  in  the  Fallopian  tube  gives  it  a 
more  or  less  characteristic  shape.  This  is  a  strong  diagnostic 
point.  A  pyriform  swelling  with  its  small  end  at  the  uterine  horn 
is  indicative  of  a  dilated  tube.  In  the  case  of  hydrosalpinx  and 
hematosalpinx  there  is,  as  a  rule,  no  complicating  jx>ritonitis, 
therefore  the  diagnosis  is  easier  than  in  the  case  of  pyosalpinx, 
which  is  apt  to  be  surrounded  by  exudate.  Hydrosalpinx  anil 
hematosalpinx  never  reach  the  great  size  of  exceptional  cases  of 
pyosalpinx.  It  is  unusual  for  any  variety  to  be  more  than  an  inch 
and  a  half  (3  cm.)  in  diameter  or  five  inches  (12  cm.)  long.  The 
hydrosalpinx  has  a  thin  wall,  and  fluctuation  can  be  determined 
without  much  difficulty;  pyosalpinx  ha.s  thick  walls  because  of 
inflammatory'  action  in  thc^  tube  and  also  in  the  peritoneum  sur- 
rounding it,  and  it  is  not  ea^^y  to  make  out  fluctuation. 

5.  Encapsulated  Peritonitis. — If  a  (juantity  of  serous  or  purulent 


SMALL  OVARIAN  TTIMORS 


299 


exutlatc  in  the  case  of  pvl\'\v  iN*ritonitis,  or  n  qiuuitity  of  nsritic 
Hiiid  biH^'onies  encai>sulate(l  by  peritoneal  adh(»j«ion«,  the  c*on(liti(»n 
may  b:  mistaken  for  a  eysttr  tumor  of  the  ovary.  Such  a  eondi- 
tion  IP  relativt'iy  rare,  however.  Generally  there  is  evidence  of 
tul^TCulosis  or  careinosis  or  aetinoinyeosis  of  the  peritoneimi  and 
the  manifestations  of  the  disease  in  the  general  cavity  of  the  peri- 
toneum oA'ers^hadow  those  in  the  (R*l\ie  cavity,  Sueli  circum- 
si^rib^l  collections  of  flui<l  in  the  |x>lvic  cavity  have  an  irregular 
shajic  and  are  not  often  nnrnd.  Also  fluid  is  apt  to  be  present  hi 
other  {Kirtions  of  the  peritoneum, 

6*  Echinococois  Cyst. — Kchinocoeciis  cyst  of  the  pehis  is  rare. 
Primary  ecliinoeorcus  disease  of  the  ovary  is  unknown,  but  it 
occurs  in  tln^  fnllowing  situations  in  the  jyehis;  (a)  the  uterus* 
(b)  the  mesometrium,  (c)  the  im^Ivic  lj<^nes,  (d)  the  omentum,  aritl 
(e)  the  Fallopian  tubc*s,  ^\l.so  downward  extension  of  hydatiil 
disease  of  the  hver  may  reach  the  jx^lvis,  Eeliinococcus  cyst  is 
round  and  fluctuates;  but,  as  a  rule,  is  more  distended  and  has 
thicker  walls  than  an  ovarian  tumor,  an*!  it  is  generally  densi^Iy 
a/_lherent  to  the  surrounding  structures.  Bland-Sutton  (^'Surgical 
Diseases  of  the  Ovaries  ami  Fallopian  Tul>es,"  1891,  p,  183)  says 
that  a  '*  {X^culiar  sign — liyatid  fremitus — can  sometimes  be  obtainnl 
by  placing  the  palm  of  the  left  hand  u]>on  the  tumor  and  shar|>ly 
jMTcussing  with  the  finger  of  the  right.  It  is  a  peculiar  tremor  or 
thrill,  only  felt  over  a  hyatid  cyst."  In  this  country  hydatid  dis- 
ease is  very  rare. 

7.  Extra-Uterine  Pregnancy* — ^lliis  gives  a  history  of  pregnancy. 
Before  rupture  there  Is  a  boggy  fluctuating  or  elastic  tumor  at  the 
side  and  Imek  of  the  utenjs.  It  is  the  shape  of  a  distended  tulje. 
Ltx>k  for  i>ui7>le  discoloration  of  the  vaguia  with  increased  dis- 
charge, and  for  changes  in  the  breasts  together  with  uterine  en- 
largement and  softening  of  the  cervix,  also  pain  on  moving  the 
cervix.  Alx)ut  the  time  of  intra-ab<lominal  rupture  of  the  preg- 
nant sac  the  endometrium  casts  otT  a  motUficd  decidua  of  pregnancy 
with  more  or  lea^  uterine  hemon*hage.  At  the  time  of  rupture  th«^ 
symptonLs  are  those  of  intra-ahlominal  hemorrhage  and  an*  urgent. 
There  is  a  fulness  in  the  cul-<!e-sac  with  alnlominal  distention, 
rapid,  fwble  pulse,  severe  i>ain  in  the  alxlomen,  and  collapse.  If 
in  a  chronic  case  a  hematocele  has  form(*fl,  there  is  a  boggj"  mass 
m  the  cul-de-sac,  generally  filling  the  pehis,  the  uterus  being  in 


300  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

front.    There  may  be  a  history  of  repeated  attacks  of  pain  recurring 
at  irregular  periods. 

8.  Normal  Pregnancy. — Early  normal  pregnancy,  particularly  if 
the  pregnancy  begins  in  one  horn  of  the  uterus,  may  be  mistaken 
for  ovarian  cyst.  It  should  not  be  forgotten  that  the  two  condi- 
tions frequently  coexist.  First,  the  history  indicates  pregnancy. 
Inquire  for  amenorrhea  and  morning  nausea  and  whether  there 
has  been  coitus.  The  uterus  in  pregnancy  is  antoflexed,  there  is 
bulging  of  the  lower  uterine  segment  anteriorly,  the  uterine  tissues 
have  a  peculiar  elastic  feel  and  are  compressible  by  bimanual 
touch  (Hegar's  sign;  see  Fig.  178).  The  cervix  is  soft  and  there 
are  increased  vaginal  discharge  and  purplish  discoloration  of  the 
anterior  vaginal  wall  and  introitus  vaginsp,  noticeable  as  early  as 
the  sixth  week  in  some  instances,  though  usually  not  quite  so  early. 
The  breasts  are  full,  the  veins  showing  in  the  skin;  the  areolse  are 
pigmented  and  show  enlargement  of  the  follicles.  There  may  be 
secretion  from  the  breasts.  In  the  case  of  pregnancy  in  one  horn 
of  a  bifurcated  uterus  the  history  of  pregnancy  is  to  be  obtained. 
There  is  no  bulging  of  the  lower  uterine  segment,  but  the  other 
signs  of  pregnancy  are  the  same.  There  is  no  fluctuation  in  the 
pregnant  uterus  until  the  stage  of  "ballottoment."  This  is  not 
available  as  a  diagnostic  sign  until  the  twenty-first  week  of  preg- 
nancy when  there  is  sufficient  fluid  in  the  amnion  and  the  fetus  is 
hea^y  enough  to  give  the  characteristic  feeling  as  the  fetus  bobs 
about  when  jostled  by  the  sudden  impact  of  the  examiner's  finger 
in  the  vagina. 

9.  A  Distended  Urinary  Bladder. — If  the  ndes  for  the  preparation 
of  the  patient  for  an  examination  have  been  observed  (see  Chapter 
IV.,  page  23)  it  will  have  been  learned  that  the  patient  has  been 
unablcj  to  urinate,  and  therefore  a  catheter  has  been  passed.  It 
sometimes  ha{)pens  that  a  patient  is  unabk^  to  speak  the  language 
or  is  unconscious,  and  the  question  of  ovarian  tumor  arises.  It 
is  safe  to  i)ass  the  catheter  if  there  is  the  slightest  doubt  that  the 
bladder  is  empty.  Upon  palpation  the  full  bladder  is  not  so  mov- 
able as  an  ovarian  cyst,  as  a  rule,  and  the  uterus  is  retroverted 
under  the  bladdcT.  Dribbling  of  urine  is  apt  to  be  a  symptom  of 
an  overfilled  bladder. 


302 


DUGXOSIS  OF  DISE.\SES  OF  THE  OVARIES 


ciaii  may  Iw*  able  to  distinguish  the  situation  and  characteristics | 
uf  the  \khMv.     (See  Fig,  120,  page  30L) 

Inspection. — Inspcetion  of  the  ahdonien  of  a  woman  having  a 
riioderatt'ly  large  ovarian  tumor  will  show  the  enlargement  most 
]>t'onouneed  o!i  the  iAde  from  w^hit^h  the  tumor  has  sjjrung.  This 
is  not  the  case  with  very  large  tumors.  As  a  rulr*  the  enlargement 
is  in  the  lower  j>ortion  of  the  al>t!oTnen.  II  C  Hirst  (^*  Diseases  of 
Women,"  Serond  E(htion,  p,  /k]9)  has  seen  three  eases  in  which 
an  ovarian  tumor  wus  in  the  upiKT  alxlomen — twice  clue  to  tight 
lacing  and  once  to  tlie  fact  that  the  tumor  was  elevated  in  preg- 


Liull 


lympanjttc 


^ 


-Tympimitic 


iS-^-^  ^~>^ 


iS. 


Fwi.   127. — Diiignim  of  a  Cross  Section  uf  llie  Bcwiy  in  (he  Tiise  of  an  Ovarian 

Tumor. 


nancy,  iTecame  adherent  to  the  liver,  and  did  not  descend  with 
invijiutinn  of  the  uterus. 

When  the  tumor  has  Ihh'u  long  existent  we  expect  to  find  the 
fttriefS  ovarina  and  lrj.ss  of  flesh  about  the  chest  and  sliouldcrs. 
Unless  ascites  is  pi-esent  or  the  tumor  is  excessively  large,  theits  is 
n(>  bulging  in  tlie  Hanks. 

Palpation. — Palpation  usually  shows  a  fluctuating  tumor,  more 
distinctly  felt,  on  the  affected  siile.  Thv  elasticity  will  depend  on 
the  sort  of  tumor  present,  and  on  tfie  tenseness  of  the  cyst.  If 
the  tumor  is  very  tense  it  may  feel  like  a  solitl  mass.  It  is  rare 
for  Bolid  tissues  to  prtMlominate  in  ovari.Hn  tumors.  Nodules  may 
be  ft>lt  and  !t>culi  of  a  multilornlar  tumor  if  the  aUhKininal  walls 
are  thin.     If  the  walls  are  verv  tense  or  tliick  it  is  neeessan^  often  to 


LARGE  OVARIAN  TIMOR^ 


303 


mlmmiKtcr  an  aiu'sthutie  bcforo  a  satisfactory  examination  can 
be  inatlr.  The  mobility  of  the  tunior  ilcpencls  on  the  lerij2:th  of  its 
}K'(licle,  the  relation  lM:*tweeii  the  .size  of  the  tumor  and  the  ^ize  of 
its  alxloinen,  and  the  presc^nee  of  atlhesinns. 

By  means  of  the  ItiMiaiiUiil  vagiiioalxloniinal  or  recto-alHloniinal 
touch  it  may  Ix'  poanible  to  rk^terniine  that  the  uterus  is  not  eii- 
lurgecl  an<I  is  ^!e|>arat»'  from  the  tumor^  and  the  pedide  may  l)e 
ma|>ped  out  by  traetinn  on  the  uterus.  Also  the  coimection  of  the 
tumor  may  Ix*  made  jilairi  l»y  moving  the  tumor  suddenly,  the  im- 


-^*v 


v^^ 


a\^ 


^ 


Flo.  128. — LariTi^  Parnvarian  Cyst  8c^n  in  Prufile.     (Kelly.) 

puke  transmittrii  tn  \\\v  uterus  Ix^ing  apj^reeiateil  by  the  fioger  in 
the  vagina  or  reetuni. 

Percussion. — W'itli  lln'  patient  in  tlie  dorsal  position  the  tumor 
oceupii'8  the  lower  anterior  portion  of  the  alxlomen.  The  intes- 
tin(»8,  helil  Ijy  their  mesentery,  are  nearer  the  diaphragm  and 
at  the  side^s  of  the  tmiior;  therefore  tyinpanitie  resonance  is  found 
in  the  epigastriimi,  flatiieas  over  the  tumor,  and  dullness  or  mixli- 
fied  resonance  in  t!ie  flanks.  These  areas  of  resonan<M',  flatness,  an<l 
dulhi(*Ns  do  not  cliange  with  change  in  the  [losition  of  the  patient, 
as  n'ganb  the  sitle  pasition  or  the  f^tanding  position.  If  the  turum* 
contains  fluid,  si  jHTcussion  tmve  may  be  elieittnl  by  [ilacing  a  hand 
on  each  side  of  the  alxlomen  and  then  tapping  witti  tlie  finger  of 


304 


DUGNO^IS  or  DISE.VSES  OF  THE  OVARIES 


one  hand.  A  vibration  will  be  felt  by  the  opposite  hand.  If 
the  abdominal  walls  are  vciy  fat  the  fat  may  transmit  a  wave  by 
itself;  therefore,  to  eliminate  this  fat  wave  have  an  assistant  place 
a  hand  with  the  uhiar  edge  down  along  the  middle  line  of  the  ab- 


Fig.  129. — The   Various  Abdominal  Organs  from  Which  Timiors  May   Arise. 

(Kelly.) 

domen  and  press  firmly.     If  the  fluid  in  the  cyst  is  thick,  as  in 
dermoids,  the  percussion  wave  may  Ik»  slight  or  absent. 

Measurements. — Measurements  of  the  abdomen  show  an  incrcas<» 
or  decrease  in  the  size  of  a  tumor  from  time  to  time.    They  arc 


LARGE  OV.IRIAN  TUMORiJ 


305 


made  with  a  tajx*  mca^surc?  at  some  (Icfmitc  point,  as  aliotit  tlic 
body  at  the  umljiliciit!,  or  at  tho  anterior  ^ujKTior  f^pine^  of  the  ilia. 
Other  measurements  are,  the  distance  from  tlie  tip  of  the  eiisi- 
form  cartilage  to  the  upixT  margin  <»f  the  sympliysis  pubi.s  antl 
a  measurement  made  with  the  pelvimeter,  the  patient  btnng  in  a 
standing  position,  fronj  the  upper  apc^xof  Mieliaelis'  rhomfjoid  area 
on  the  baek  over  the  saerum,  to  the  most  ]>rominent  [joint  of  the 
tumon  These  measurements  must  be  taken  eacli  time  with  the 
patient  in  exactly  the  same  position,  wliether  standing  or  on 
the  side  and  always  with  tlie  Ixjweb  free. 

Aspiration  or  tapping  an  ovarian  tumor  is  never  justifialile  a,s  a 
means  of  diagnosis,  and  exploratory  incu'^mi  is  to  be  praetict^l  only 
when  it  is  impossible  to  make  a  diagnosis  and  all  the  prejiarations 
have  been  made  for  a  complete  operation. 


Differential  Diagnoaiis  of  Large  Ovarian  Tumors 

We  must  rule  out: 

1.  Pregnancy. 

2.  Ascites. 

3.  Fibroids. 

4.  Aecunnilations  of  gas  or  fecal  matter  in  tlie  intestines, 

5.  Fat  or  tumors  in  tlie  alxlominal  walls,  including  ''Phantom 

Tumor/' 

6.  Cyst  of  tlie  panei*eas. 

7.  Tumors  of  the  spleen,  hv<,"r,  and  kidneys, 
S,  Cyst  of  the  omentum. 

9*  Eehinococcus  cysts- 
10.  Dilateil  stomach. 
n.  Disiendal  urinary  bladder, 

I.  Pregnancy.— It  should  be  tissumed,  mitil  the  contrary  has 
been  proven,  tliat  every  abiominal  *»nlargenient  in  a  woman  is 
due  to  pregnaney.  In  this  way  many  enjbai'ra.Nsing  mistakes  will 
be  avoided*  The  diagnosis  of  early  pregnaney  has  bi'en  eonsidered 
in  treMing  of  the  small  ovarian  tumors-  Advanced  pregnancy  is 
to  be  excluded  by  t!ie  history.  It  is  possible  to  have  amenorrhea 
in  ovarian  tumor,  especially  where  both  ovaries  have  become  dis- 

20 


306 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


organized  by  the  disease  affecting  them,  but  it  is  unusual.  Morn- 
ing nausea  and  vomiting  during  the  early  months,  or  salivation 
and  heartburn  and  swelling  of  the  breasts,  are  characteristic  of  preg- 
nancy. Sometimes  these  symptoms  have  occurred  at  a  given 
time  with  previous  pregnancies.  Ask  whether  they  have  bec^n 
observed  this  time  since  the  patient  first  noticed  the  enlargement 
of  the  abdomen. 

Quickening  is  usually  noticed  at  the  end  of  the  sixteenth  w^(»ek 
of  pregnancy.    The  signs  of  pregnancy  in  the  later  months  an* 


Fig.  130. — The  Height  of  tlie  Fiiiulus  I'teri  iit  the  Various  Weeks  of  Pregnancy 

(Aft^r  Zweifel.) 

softc^iing  of  the  cervix,  increased  vaginal  discharge,  ballottoment 
after  the  twenty-first  week.  Fluctuation  in  the  uterus  is  vcTy 
indistinct  unless  the  litjuor  anmii  is  hi  (wcess  and  the  uterine  walls 
are  thin  from  juiy  cause.  By  can^ful  palpation  the  intermittent 
rhythmical  contractions  of  the  pregnant  uterus  may  be  felt  as 
early  as  th(^  fouith  month.  A  good  deal  of  patience,  gentleness, 
and  skill  ai'e  necessary  to  get  this  sign.     Purplish  discoloration 


LARGE  OVARIAN  TUMOK8 


aor 


of  the  viilva  aiid  anterior  wall  of  Uir-  vagbia  are  to  Ik?  ma^ic  out  fmin 
the  sixth  to  the  twelfth  week.  If  milk  or  colost  rum  can  l)c  squeeze^ 
from  the  breasts  it  is  an  inifxirtant  imiicatiou  of  prc^iancy. 

Fetal  heai-t  sounds  ca!i  h}  heartl  aftiT  the  twentieth  wei'k,  and 
fetal  nio%'enients  can  Ix^  felt  after  tlie  sixte<^nth  Mxrk  unless  the 
fetus  is  deacL  The  tumor  has  develo[X'd  relatively  rapidly;  there 
is  pigmentation  of  the  areohe  of  the  nipples,  and  of  the  hnc^a  alba 
in  sonic  eases;  edema  of  the  ankles  is  not  uncommon  after  the 


^ 


^-^V 


'r*, 


Jtia£i^ 


,_^*^ 

^:^       ^ 


Flu.   131-— Iht'  Al"lonien  of  Ascit4?«  Seen  in  Profile.     (KrllyJ 


BPventh  month;  the  face  shows  sometimes  the  faeies  uterina^  a 
fnlhii'ss  al>out  the  eyes  and  fn>ut  of  the  elieeks. 

Lin  the  ease  of  an  ovarian  tumor  theix^  is  no  softening  of  the 
cemx;  the  tumor  is  distinct  from  the  uterus  and  is  of  gradual 
development;  thert*  is  no  ballottement  and  tlien*  are  no  fetal  heart 
sounils  or  moveTuents;  also  there  is  absence  of  [Jirniientation  of  the 
areohe  and  the  linea  alba;  edema  of  the  ankles  is  rare,  excej>t  after 
P  tumor  has  cxisteil  Sfweral  years;  the  superficial  veins  of  the 
alxiouien  are  enlarged,  and  the  faeies  ovarina  is  pre-sc»nt  in  the 
vii^*  of  long-existing  tumors, 

Hydranmios,  an  excci^i^  of  anmiotie  \Uiu\,  lias  M  many  a  surgeon 
to  diagnose  ovarian  cyst.  A  careful  study  of  the  hisiorjr,  synijv 
toms  and  signs  of  pregnancy  and  ovarian  tumor  ought  to  make 


308 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


differentiation  relatively  easy  and  sure.  In  ovarian  cyst  the 
tumor  is  of  less  rapid  development,  there  is  no  ballottement,  and 
the  tumor  is  more  on  one  side  than  the  other,  and,  most  important, 
it  is  distinct  from  the  uterus. 

2.  Ascites. — ^An  accumulation  of  fluid  in  the  peritoneal  cavity 
may  accompany  an  ovarian  tumor,  and  in  such  a  case  the  diagnosis 
is  difficult,  and  may  be  settled  exactly  only  at  the  operation  und(T- 
taken  for  the  removal  of  the  tumor. 

The  following  table,  taken  from  Dudley's  "Gynecology,''  with 
modifications,  gives  the  points  which  serve  usually  to  distinguish 
ascites  from  ovarian  cyst. 


Ascites. 


Large  Ovarian  Cyst 


1.  Previous  liistory  of  disca^  of 
kidneys,  heart,  or  liver,  or  peritoneum. 

2.  Enlargement  comparatively  sud- 
den. 

3.  Face  puffy;  color  waxy;  early 
anemia. 

4.  With  patient  in  dorsal  position 
symmetrical  enlargement  of  abdomen, 
bulging  in  flanks  and  flat  on  top. 

5.  With  patient  sitting  the  abdomen 
bulges  below. 

6.  Navel  prominent  and  thinned. 

7.  Fluctuation  decided  and  diffuse 
throughout  abdomen,  but  is  absent  in 
the  highest  parts.  Modified  on  change 
of  position. 

8.  Intestines  float  on  top  of  liquid, 
therefore  i)ercu8aion  gives  a  tympanitic 
note  in  the  upper  portions  and  flatness 
in  the  flanks  when  patient  is  on  her 
back.  Change  in  position  changes  po- 
sition of  intestines  and  of  resonance 
to  the  highest  part  of  the  abdomen. 

9.  Vaginal  palpation  shows  bulging 
into  the  posterior  cul-de-sac. 

10.  Uterus  prolapsed,  but  size  and 
mobility  unchanged. 


1.  No  such  history 

2.  Gradual. 

3.  Facies  ovarina,  anemia  relatively 
late. 

4.  Asynunetrical  until  tumor  is  very 
large,  jxiaked  on  top. 

5.  No  change. 

6.  Navel  imchanged  usually. 

7.  Less  distinct  and  limited  to  the 
cyst.  Not  modified  by  change  in  po- 
sition of  patient. 

8.  Intestines  occupy  same  position 
all  the  time.  No  change  in  percussion 
with  change  in  position  of  patient,  i.e., 
flat  over  cyst  and  resonant  above  it 
and  to  one  side,  the  side  opposite  to 
that  from  which  the  cyst  sprung. 

9.  No  bulging  into  the  cul-de-sac. 

10.  Uterus  displaced  by  the  cyst, 
mobility  limited  by  the  tumor. 


Encysteh  (m-ites^  or  fluid  oonfincnl  to  a  limited  part  of  the  ab- 
dominal cavity  by  adhesions,  may  give  the  same  areas  of  dullness 
and  resonance  as  an  ovarian  cyst. 


3.  Fibroids. — There  i.s  caiisi»leral>le  (laiigcr  of  coiifui^ing  a  largr 
fibroiiiyouia  of  the  utcirus  wiih  ii  large  ovarian  cyst.  The  followuig 
table,  eoiTipilt»<l  from  several  authoi>^  ami  from  my  o\^Tl  experience, 
|M)irit8  out  the  cliief  features  in  the  differential  duigua*?is; 


I 


iMrge  Uterine  Fibrmd. 

\,  Menorrhagia  or  metrorrhagia 
roiiimoii  where  the  growth  is  intersti- 
tial in  part. 

2.  General  health  not  nert-ssarily  im- 
paired, except  aneiiiia  from  loss  of 
blood  or  debility  from  pain*  Palpita- 
tion of  heart  common. 

3.  Barely  occurs  in  early  Ufc, 

4.  Slow  growth. 

5.  Apt  to  be  afiymmetricaland  nodu- 
lar; tuinora  commonly  multiple. 

6.  Consistency  firm,  elastic,  or  harcL 

7.  Uterus  largtj  and  ca\'ity  enhir^t^d 
if  growth  is  interstitial.     Tumor  a  part 
of  uterus  or  connected  by  a  short  and 
thick  pedicle- 
s' Uterine  bruit  by  auscultation  in 

half  of  the  cases, 

9.  No  cliange  in  facial  expression  un- 
less pale  from  hemorrhage. 

10.  Superficii&l  vmiis  of  abdomen  not 
enlarged. 


Large  Ovarian  CyM. 

1 .  Menstruation  unchanged  or  dimin- 
ished in  amount. 

2.  General  health  iiapilied  9aafy. 
No  pain  exce])t  in  the  ease  d  adbedcmi, 

or    other    compli cations.     Palpitation 
uncommon. 

3.  May  occur  in  infancy. 

4.  More  rapid  growth. 

5.  Symmetrical;    may  be  lobulated. 

6.  Fluctuating. 

7.  UtenLs  not  enlarj^eii  Tumor  con- 
nected with  it  only  by  ].>etUcle,  which  is 
apt  l<i  be  relatively  long. 


8.  Absent. 

9.  Facies  ovarina  and 
about  neck  and  chest. 

ID.   Veins  enlarged. 


IpMof  fie^ 


It  must  not  be  forgotten  that  beoaiLse  of  ilegenerative  proo 
esBCs  in  a  uterine  fibroid  then*  may  be  fluid  in  the  tumor  antl 
fluctuation  will  he  fr»un*l,  and  that  in  some  of  the  ovarian  tumors 
with  i^olid  eontents  fluctuation  may  te  absent.  As  stat-inl  Ix'forej  it 
is  never  ju^stifiable  to  tap  a  tumor,  a  proeedure  once  much  in  vogue 
for  the  purpose  of  diagnosis,  Ix'eaus*/  som**  of  the  fluiil  is  almost 
?*ure  to  escape  into  thi^  peritont^al  cavity  and  to  t*ause  peritonitis 
of  a  grade  and  severity  depending  on  the  character  and  amoimt 
of  fluid  extrava.sated. 

4.  Accumulation  of  Gas  or  Fecal  Matter  in  the  Intestines.— Tym- 
panites has  Ijetm  mistaken  for  ovarian  cyst.  Accnnmlatcd  gas 
gives  a  tympanitic  not4.*  on  percussion,  the  gurghng  of  gas  in  the 
bowels  may  be  heartl  by  auscultation,  and  there  is  an  absi?nce  of 
a  fluid  wave  on  paljjation.      By  the  vaguml  touch    tluTc  is  an 


310 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


af^sc^ncc!  of  the  finn  elasticity  eommiinieate<l  by  a  fluid  or  solid 
tumor.  In  the  case  of  fecal  accunuilation  there  is  a  liistory  of 
chronic  constipation  and  the  distended  bowel  will  pit  on  pressure 
by  aljdominal  or  vaginal  touch.  Active  catharsis  removes  the 
tumor. 

5.  Fat  or  Tumors  in  the  Abdominal  Walls,  including  "Phantom 
Tumor." — ^A  thick  panniculus  adiposus  may  simulate  an  ovarian 
tumor  and,  strange  as  it  may  stH^m,  well-kno\\Ti  surgeons  have  opc^- 
atcnl  for  tumor  under  such  conditions.  Grasping  the  abdominal 
walls  in  the  hands,  it  is  possible  in  most  cases  to  determine  that 
th(^  fat  is  in  the  substance  of  the  wall  rather  than  in  the  abdominal 
cavity.    Edema    of   the    abdominal    walls   sometimes   simulates 

Central  part  of  abdomen 
Tympanitic 


Fi«.  132. — Diagram  of  a  Cross  Section  of  the  Abdomen  of  Ascites,  Dorsal 

Position. 

tumor.  In  this  case  we  expert  to  find  i)itting  on  pressure  and 
evidenc(\s  of  edema  elsewhere*. 

Tumors  of  the  anterior  alxlorninal  waDs  consist  of  fibromyoma 
of  th(^  nrtus  muscle  and  cysts  of  the  urachus.  They  are  of  un- 
common occurrence. 

Fibromyoma  of  the  Rectus, — ^Two  instances  of  this  have  fallen  under 
my  ()bs(MA^ation.  Both  patients  w(Te  twenty-nine  years  of  age  and 
moth(»rs  of  families.  One  was  svvn  with  Dr.  F.  W.  Johnson,  of  Ba^ 
ton,  in  consultation,  March  18,  1892,  and  operated  upon  by  him  the 
same  day  in  my  pn^sc^nce.  Here  there  was  a  tumor  of  soft  consist- 
ency, the  size  of  a  Florida  orange,  in  the  l(^ft  epigastric  region.  The 
other  was  a  patient  operated  upon  by  me  October  23,  1896.  In 
this  case  tlierc*  was  a  sonu^what  smaller  tumor  of  harder  consistency 
in  the  right  rectus  muscle,  just  b(4()w  th(*  k^vel  of  the  umbilicus. 


LARGE  OVARIAN  TUMORS 


311 


Both  were  entirely  extraperitoneal  and  were  pronoimced  by  the 
jiatliolugi^t  ti»  Ix'  fil>njinyuina. 

Ct/sLs  of  lite  urachus  tlevelojf  in  the  iiornuilly  inii>ervious  vord 
wliich  runs  from  the  bladder  to  thi*  umbilicus.  Like  tlie  bUidder 
it^If,  a  cyst  of  the  itraehus  represents  a  persi&tent  portion  of  the 
allantoic.  A  cyr^  as  large  us  the  urinary  bladder,  or  larger,  may 
form  in  the  eours<'  of  the  iiraehu^.  Such  a  eyst  is  situated  Ix'twtvn 
the  fascia  and  the  perituneum  on  the  insitle  of  the  aUlomiiial 
parietes,  in  the  median  line.  It  is  to  be  differentiated  from  an 
ovarian  cyst  by  its  absence  of  coruif*elion  with  the  uterus  or  its 
ap|K^ndaget^,   by  the  greater  area  in   the  abdomen  of,  intestinal 


Formerlj  dull, 
now  cympanitJc 


Fig,   133. — ^The  Same  as  Fig,  132.  Lateral  Position,  Showing  Change  in  Situation 
of  Areas  of  Dulbics^s  and  Tympany. 

rc*sonance,  and  b)^  tlie  aliscnce  of  the  other  signs  and  ?*}Tnptoms 
of  ovarian  cyst. 

**  Phantom  Twmor. "^Pliant om  tumor  occurs  occasionally  in 
hyj^erical  women  who  have  the  jiower  of  contracting  the  nmsclt^s 
of  the  alxlonien  so  as  to  farm  a  mass  lliat  simulates  an  alKjominal 
tumor.  The  muscular  contraction  can  be  overcome  f^rnetim(»« 
in  the^e  ca>^es  by  firm  pri^ssure  of  the  hands  and  the  tumor  then 
disapix-ai-s.  There  is  exaggerated  tympany  over  the  tumor  Ix^ 
cause  the  intestines,  helrl  by  t!ie  mujsclea,  form  the  tumor.  In 
many  cases  it  is  impossible  to  make  an  exact  diagnosis  without 
etherization,  and  accordingly  it  is  well  to  etherize  a  doubtful  case 
of  phantom  tumor  or  tumor  in  the  alKlnniinat  wall. 

6.  Cyst  of  the  Pancreas, — ^The  situation  of  the  tumor  is  of  great 
importance  in  dili'(*rentiating  cyst  of  the  |)anereas  from  ovarian 
cyst.     The  fonner  develops  luxler  tlie  margin  of  the  ribri  on  the  left 


312  DIAGNOSIS  OF  DISE.\SES  OF  THE  OVARIES 

side  and  grows  from  above  downward.  If  the  cyst  is  large  the 
liver  and  stomach  may  be  displaced  upward,  while  the  transverse 
colon  is  depressed  under  the  tumor,  the  cyst  reaching  the  pelvis 
only  exceptionally  in  the  case  of  very  large  tumors.  Therefore  a 
pancreatic  cyst  can  be  confused  only  with  high-lying  ovarian  cyst. 
Pancreatic  cysts  generally  are  thin-walled  and  the  fluid  is  thui, 
consequently  fluctuation  is  marked.  The  greatest  convexity  of 
the  abdomen  is  in  the  neighborhood  of  the  umbilicus.  The  history 
given  by  the  patient  is  that  the  tumor  was  high  up  under  the  ribs 
when  first  noticed,  and  bimanual  examination  of  the  pelvic  organs 
shows  that  there  is  no  connection  between  the  uterus  and  the 
tumor  and  that  the  ovaries  are  not  enlarged. 

7.  Tumors  of  the  Spleen,  Liver,  and  Kidneys. — Tumors  of  the  spleen 
originate,  of  course,  in  the  left  hypochondrium,  have  an  oblique  posi- 
tion, and  a  peculiar  elastic  consistency.  Under  the  influence  of  de- 
generative processes  or  the  presence  of  an  echinococcus  cyst  there 
may  be  fluid  in  a  splenic  tumor.  Such  a  condition  must  be  re- 
garded as  very  unusual,  however.  In  the  case  of  uxmdering  spleen 
the  tumor  may  be  in  the  iliac  fossa,  and  may  be  mistaken  for  an 
ovarian  tumor  or  a  kidney.  Careful  palpation  of  such  a  tumor 
with  the  aid  of  an  anesthetic  will  show  one  or  more  notches  in  the 
anterior  border  and  perhaps  a  vertical  slit  at  the  hilum.  Palpa- 
tion of  the  kidney  regions  will  show  the  presence  of  the  kidneys 
in  their  normal  situation.  It  has  been  suggested  by  H.  A.  Kelly 
(Kelly  and  Noble,  *^  Gynecology  and  Abdominal  Surgery,''  Vol.  II., 
p.  597)  that  by  passing  a  renal  catheter  and  injecting  the  kidney 
with  enough  fluid  to  produce  a  mild  renal  coUc,  the  pain  will  be  re- 
ferred to  the  lumbar  region  and  not  to  the  splenic  tumor.  Exami- 
nation of  the  pelvic  organs  ought  to  exclude  uterus,  tubes,  and 
ovaries  from  participation  in  the  tumor.  A  wandering  spleen  has 
been  knowTi  to  become  lodged  in  the  pelvis  and  there  to  obstruct 
the  intestine  (case  of  Korte,  cit(Ml  by  J.  Bland-Sutton,  Brit.  Med, 
Jour,,  1897,  p.  132),  and  J.  C.  Webster  {Jour.  Avier,  Med,  Asso,, 
1903,  Vol.  XL.,  p.  887)  has  reported  a  case  of  wandering  spleen 
that  occupied  the  right  iliac  fossa. 

Tumors  of  the  liver  may  be  confused  with  ovarian  tumors  if 
they  reach  do^\^lward  to  the  pehis,  or  if  during  late  pregnancy 
an  ovarian  tumor  has  become  fixed  to  the  liver  by  adhesions,  so 
that  upon  involution  of  the  uterus  the  tumor  remains  in  the  upper 


LARHE  OVARIAN  TUMORS 


313 


ul>lniiirn,  Tlir  lirru,  hard  eonsisteney  of  llic  liver  is  more  or  less 
eharacteristic,  also  its  sharp  lower  Ijordtvr,  which  is  plaetnl  obliiiuely 
to  the  ensiform  cartilage  and  is  indented  witli  a  notch  for  the  gall 
blailder.  Also,  all  liver  tumors  move  more  or  less  on  deep  respira- 
tion, except  acceasory  lobes^  very  large  tumors,  and  echinococcus 
disease.  The  peKic  oi-gans  are  investigates!  and  the  relation  of 
the  tumor  to  the  liver  tested  by  moving  the  tumor  atx)ut  and 
noticing  if  the  liver  is  moved  also. 

Tumors  of  the  kidney  are  not  of  frequent  occurrence.  The  most 
common  are:  hypeniephroma  and  {lapilkr}^  cystoma.  Malignant 
timiors  afl'eet  especially  the  yomig  and  the  old.  Heinatmia  is 
present  in  almost  all  malignant  tumors  of  the  kidney;  pain  in  the 
region  of  the  kidney  is  a  less  common  symptom.  Hypernephroma 
is  a  tumor  arising  from  adrenal  tissue  but  involving  the  kidney  in 
practically  ah  instances.  The  tumor  is  lobulated  and  extends 
toward  the  metlian  line.  It  is  malignant  and  has  metastases, 
most  commonly  in  thi^  lungs  and  liver,  ' 

Polycystic  duea^sie  of  tlie  kidney  consists  of  a  cystic  degeneration 
of  the  kidney  parenchyma,  and  the  tumor  is  like  a  bunch  of  grapes. 
Many  of  these  tumors  are  congenital  O^ngenital  kidney  disease 
is  apt  to  be  associated  mih  tlisease  of  the  ovaries,  as  the  two  de- 
velop together  in  fetal  life.  Ecliinococcus  cysts  develop  in  the 
kidney  in  5.8  per  cent  of  all  cases  of  hydatid  diseases  The  tumor 
grows  slowly  and  f<;>rms  a  smooth,  roimd,  movable  nm.ss. 

A  movable  kidney  may  get  as  low  as  the  p<:J\is.  Its  sha{x*  is 
characteristic.  Hydronephrasis  may  accompany  renal  tumor  and 
in  this  case  the  urine  will  show  abnormal  constituents. 

Cydic  tumors  or  simple  eyst.^  of  iJte  kidney  arise*  m  the  outer  part  of 
the  cortex,  and  may  attain  great  size.  Such  a  cyst  is  to  be  diffti*en- 
tiateil  from  an  ovarian  cyst  by  its  kx-ation  in  the  flank,  its  relative 
inunobilityj  and  by  its  not  Ixing  connected  witli  the  uterine  organs 
as  i>rov*Hl  by  the  bimanual  <*xamination.  If  the  uterine  organs  are 
normal  the  difTfTcntiation  is  easier  than  if  they  are  tUsc^ased. 

8.  Cyst  of  the  Omentum. — t'ysts  of  the  omentum  are  mostly  flat 
and  sliield-sha|)ed;  they  are  very  freely  movable,  and  can  he  ro- 
tattnJ  Si:»  that  in  some  cases  the  fjosterior  jxirtion  of  the  cyst  may 
l3e  palpatiMJ.  They  arc  of  infrecjucnt  occurrence,  and  it  is  gener- 
ally easy  to  determine  that  the  cyst  has  no  connection  with  the 
uterine  oi^gans. 


J 


314  DIAGNOSIS  OF  DISK4SES  OF  THE  OVARIES 

9.  Echinococcus  Cysts. — Echiiiococcus  disease  may  be  confused 
with  ovarian  tumor  especially  if  it  involves  structures  in  the  p(»lvis. 
It  has  been  referred  to  as  occurring  in  the  liver,  spleen,  and  kid- 
neys. In  the  pelvis  it  occurs  in  the  following  situations  according 
to  Bland-Sutton  ("Diseases  of  Women,''  Bland-Sutton  and  Giles, 
p.  388):  (a)  The  uterus;  (6)  the  mesometrium;  (c)  the  pelvic  bones; 
(d)  the  omentum;  (e)  the  Fallopian  tubes.  There  is  no  authentic 
case  on  record  of  primary  echinococcus  cyst  of  the  ovaiy.  Large 
tumors  may  develop  in  any  of  the  structures  named.  As  a  rule, 
they  form  part  of  a  general  invasion  of  the  subperitoneal  tissues. 
The  colonies  are  apt  to  communicate  with  the  vagina,  bladder,  or 
rectum  and  the  characteristic  vesicles  escape  with  the  urine  or  feces. 
Bland-Sutton  says,  "The  clinical  recognition  of  echinococcus  cysts 
in  the  pelvic  organs,  mesometrium,  or  bones  is  sometimes  made  by 
a  sort  of  'lucky  guess'  when  other  and  more  conmion  diseases  can 
with  certainty  be  excluded.  Occasionally  when  a  patient  seeks 
advice  for  pelvic  trouble,  and  brings  '  vesicles '  which  have  escaped 
by  the  rectum,  vagina,  or  urethra,  much  speculation  is  spared. 
When  the  bones  are  eroded  and  swellings  form  under  the  skin, 
they  are  punctured,  and  characteristic  fluid  with  vesicles  and 
booklets  escapes,  and  so  the  diagnosis  is  established.  When  the 
cysts  suppurate  the  physical  signs  are  those  of  abscess." 

10.  Dilated  Stomach. — Careful  percussion  of  the  stomach  area, 
auscultation  of  the  abdomen  while  the  patient  swallows  a  mouth- 
ful of  water,  the  appreciation  of  a  gurgling  sound  all  over  the  region 
occupied  by  the  stomach,  and  the  situation  of  the  maximum  of 
enlargement  of  the  abdomen  above  the  umbilicus,  ought  to  deter- 
mine the  presence  of  a  dilated  stomach.  If  there  is  a  doubt  ad- 
minister an  effervescent  mixture  and  practice  percussion  when  the 
stomach  is  distended  with  gas. 

11.  Distended  Urinary  Bladder. — ^The  bladder  may  rise  as  high 
as  the  umbilicus  when  overdistended  and  may  present  the  appear- 
ance of  an  ovarian  cyst.  (Sec  Fig.  85,  page  217.)  The  bladder 
tumor  is  in  the  median  line,  close  held  to  the  back  of  the  arch  of 
the  pubes;  it  bulges  into  the  vagina,  distending  the  anterior  wall; 
thcTe  is  almost  continuous  ovctHow  of  urine,  and  generally  hypo- 
gastric distress,  except  where  the  patient  is  unconscious  or  the 
distention  has  existed  a  long  ium\  Passing  the  catheter  removes 
all  doubt. 


rOMPLK^ATIONS  OF  OVARTAN  TUMORS 


315 


Diagnosis  ok  thi:  (*oMPLi<^\TitjNs  of  Ovarian  Tltmors 


The  rniiiplirations  to  wliii-h  ovarian  tumors  an*  sul)jcM't  an* 


L 
2, 

3. 


Adlicsittns  and  inearcfTation. 

Intraligamentous  development. 

T<jrNitin  of  the  iietlifle, 
4,  Inflect  ion  antl  .suppuration, 
.1  Degenerative  processes,  including  malignancy* 

6.  Rupture, 

7.  A-^sofiation  with  pretjjnancy. 
I.  Adhesions  and  Incarceration, — Adhesions  Iw^tween  an  ovarian 

tumor  and  its  surroimding  structures  makr  the  dia^^nosis  much 
more  difficult,  especially  in  the  ca.se  of  small  ovarinn  tumors,  thoR^ 
lying  wholly  within  the  cavity  of  the  p<_4vis.  The  history  of  at- 
tacks of  inflammation  may  give  a  clew  to  the  presence  of  adhesions, 
a^  the  occiiriTnce  of  pain.  It  is  a  w<»ll-known  fact  that  the  parietal 
peritoneum  rather  than  tlie  visceral  |RTitoneum  is  the  s<^at  of 
pain.  This  fact  has  Ixtu  dernonstrated  during  alKJominal  opera- 
tions performed  under  local  anesthesia.  Tlirrfi(»re  we  should 
expert  adhesions  to  the  parietal  jn'ritoneum  to  cause  niore  jjain 
than  those  to  the  viscera.  Extensi\x*  adhesions  nmy  occur  with- 
out any  pain  whatsoever. 

Fixation  of  a  tumor  to  a  greater  or  less  degr^^:*  intlieates  adhesions 
8S  a  rule.  The*  exception  is  the  ran*  condition  of  in4:arceraium 
'Witlund  udhesioHs,  A  tumor  may  Ix'eome  incarcerated  in  the 
pelvis,  thus  causing  obstruction  of  the  bowx-l,  or  abortion  as  in  the 
ease  of  the  retroflexetl  prr^gnant  uterus. 

An  attempt  should  tie  nia<le  to  dislotlge  an  ovarian  tumor  fixed 
in  the  pc4vis,  by  i>utting  the  ])atient  in  the  knt^e-chest  position, 
letting  air  info  the  vagina  by  means  of  the  Sims  speculum,  and  by 
making  traction  on  the  cervix  with  a  tenaculum.  I'pward  |iressyre 
on  the  tumor,  tlie  patir^nt  Ix'ing  in  the  dorsal  |)osition,  through 
cither  the  vagina  or  rectum  will,  in  many  cases,  itislodge  a  non- 
adherent tumor.  After  reposition  the  bimamia!  pal] ration  and  the 
n»ai>pmg  out  of  the  piMlieli'  jiroctHnl  with  greater  facility,  Somt^ 
times  the  shape  and  character  of  adhesions  in  the  jxlvis  can  be 
■  made  out  by  touch,  also  adhi^sions  to  the  afnlominal  walls  In  the 
I     cai?e  of  large  tumors  can  be  detennuietl  in  a  smaller  proportion  of 


I 


316  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

cases.  Adhesions  to  the  intestines,  omentum,  liver,  or  spleen  can 
not  hvt  diagnosed  with  eertainty. 

2.  Intraligamentous  Development. — If  a  tumor  has  grown  between 
the  layers  of  the  broad  ligament  it  is  immovable  and  can  not  be 
displaced  into  the  abdominal  cavity  by  bimanual  manipulation. 
It  gives  the  impression  of  being  closely  unitetl  with  the  uterus  and 
the  examiner  may  receive  the  impression  that  he  has  to  do  with  a 
fibroid  tumor  of  the  uterus.  Intraligamentous  tumors  are  gen- 
erally cystic,  however;  they  have  no  pedicle  and  sometimes  may 
be  diflferentiated  from  parovarian  cysts  by  this  characteristic. 

If  the  physician  can  decide  that  an  immovable  cystic  tumor  in 
the  pelvis  is  connected  not  only  with  the  uterus  but  with  Uie  side 


Fia.  134. — Diagram  Showing  the  Course  of  the  Utero-sacral  Ligaments  in  the 
Case  of  a  Retro-peritoneal  Tmnor. 

of  the  uterus  the  tumor  is  probably  an  intraligamentous  ovarian 
cyst.  This  may  be  done  sometimes  by  grasping  the  uterus  and 
palpating  it  separately  from  the  tumor.  The  uterus  is  commonly 
displaced  laterally  to  the  side  of  the  pelvis  opposite  to  that 
occupied  by  the  tumor.  Occasionally  the  ovary  with  its  long 
Fallopian  tube  stretching  to  it  as  a  cord  may  be  made  out  lying 
on  the  top  of  the  tumor,  and  now  and  then  the  round  ligament 
can  be  palpated  as  a  round  cord  coming  over  the  surface  of  the 
tumor  to  the  internal  abdominal  ring. 

To  distinguish  a  tumor  developing  under  the  peritoneum  in  the 
back  of  the  p(;lvis  from  an  intraligamentous  tumor  one  tries  to 
palpate  the  utero-sacral  ligaments.  If  these  are  in  front  of  the 
tumor  it  is  a  retro-peritoneal  growth,  whereas  if  the  ligaments 


COMPLICATIONS  OF  0V.4JltAN  TUMOILS 


317 


arc  bfhiod  the  tuiDor  it  is  an  intraligamentous  neoplasm.     (Sec 
Figh5.  134  and  135.) 

3,  Torsion  of  the  Pedicle, — Rotation  of  an  ovarian  tumor  on  it.s 
long  axifi  causing  twisting  of  its  jj<niii'Ie  18  l)y  no  moans  an  uncom- 
mon ha(jpening.  It  pre^supfX)«es  the  absence  of  ailhe^ions  to  sur- 
rounding fixetl  structures  such  as  the  pelvic  walls  or  the  pariete.s 
of  the  ahlomen.  It  is  more  apt  to  occur  in  tumors  of  meiliuni  size. 
To  ileteet  a  twisting  by  palliation  of  the  jHjiliele  wlicre  all  the  con- 
ditions are  most  favorable  is  a  possibility.  Ordinarily  torsion  is 
diagnosed  only  by  its  results.  The  twisting  may  be  gradual,  in 
wliieh  ease  the  tumor  adjusts  itself  to  the  lessened  blootl  supply 
caused  by  the  constriotion  of  its  jxidicle,  or  it  may  be  rapid. 


Fig,  135, — Diagram  Showing  the  Course  of  the  Utero-sacral  LigameDts  in  the 
Caae  uf  an  Intra-llg^meiitoua  Tumor, 

WTiether  gradual  or  rapid  there  comes  a  time  when  the  blond  supply 
is  cut  off,  then  ensue  in  the  cyst  eilema,enlargeuient,  supimration, 
or  even  gangrene.  Atrophy  lias  Ix'cn  known  to  oceur  in  the  ease 
of  very  small  tumors  and  eon)i>Iete  separation  of  the  cyst  from  its 
pt^dicle  in  rare  instances.  Torsion  is  apt  to  be  followed  by  adhe- 
Bions,  eti^peciall}^  adhesions  to  the  towels. 

Syniptoms  of  the  elironie  stage  of  toi-sion  may  bt*  entirety  want- 
ing, or  a  patient  may  complain  of  pains  in  the  abrlomen  especiaDy 
at  the  time  of  the  eatanienia  when  congestion  of  thr  jx^lvie  organs 
LK  normally  great^^st.  These  jmins  may  t>t*  associated  witli  nausea 
and  vomiting  and  are  apt  to  follow  violt^ut  t*xertion  or  trauma.  If 
the  testing  is  sufficient  to  cause  blood  stasis  the  sjTiiptoms  are 
those  of  general  peritonitis  and  there  is  pi*csent  an  acute  abdominal 


J 


318  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

emergency.  Acute  abdominal  pain,  rapid,  feeble  pulse,  vomiting, 
elevation  of  temperature,  and  a  rigid  abdomen  occurring  in  a  woman 
known  to  have  an  ovarian  tumor  are  symptoms  calling  for  im- 
mediate operation. 

Twisting  of  a  pedicle  of  an  ovarian  tumor  has  been  mistaken 
for  appendicitis.  Bimanual  examination  will  reveal  the  presence 
of  the  ovarian  tumor;  the  pain  caused  by  torsion  is  not  of  the  colicky 
character  of  the  pain  of  appendicitis.  Finally  the  history  reveals 
no  similar  attacks  of  pain  and  no  history  of  digestive  disturbances 
and  irregularity  of  the  bowels  as  in  the  case  of  appendicitis. 

4.  Infection  and  Suppuration. — Infection  of  ovarian  tumors  with 
streptococcus,  typhoid  bacillus,  or  bacterium  coli  communis,  is 
transmitted  by  the  blood  current,  or  from  the  intestine,  urinarj' 
bladder,  or  the  Fallopian  tube.  Formerly,  when  it  was  the  custom 
to  tap  ovarian  cystomata,  infection  was  introduced  very  frequently 
in  this  way.  Ovarian  cysts  become  infected  following  an  attack 
of  typhoid  fever,  and  in  this  case  the  bacilli,  in  all  probability,  gain 
entrance  through  the  blood.  A  patient  known  to  have  an  ovarian 
cyst  should  be  watched  carefully  for  evidence  of  infection  of  the  cyst 
following  an  attack  of  typhoid  fever.  The  symptoms  are  chills, 
elevation  of  temperature,  rapid  pulse,  pain,  and  tenderness  in  the 
abdomen. 

The  Fallopian  tube  is  a  very  frequent  carrier  of  infection  to  an 
ovarian  tumor.  This  is  to  be  inferred  because  it  is  about  the 
fimbriated  end  of  the  Fallopian  tube  that  the  densest  adhesions 
are  to  l)c  found  during  operation  for  the  removal  of  infected  cysts. 
It  is  probable  that  infection  following  puerperal  fever  reaches  a 
tumor  by  this  channel.  In  the  case  of  an  inflamed  bladder  or  in- 
testine or  veiTTiiform  appendix  the  organ  may  become  adherent 
to  a  tumor  and  the  inflammatory  process  be  carried  to  the  growth 
l)y  continuity.  The  inflammatory  process,  however  transmitted, 
may  go  on  to  mppuration.  In  this  case  there  are  to  be  noted 
sudden  enlargement  of  the  cyst,  severe  pain  and  tenderness,  rapid 
and  weak  pulse,  and  chills,  high  temperature,  and  exhaustion. 
Prompt  operation  alone  will  prevent  rui)ture  or  general  peritonitis 
and  death.  Gas  may  Ix?  fonned  in  the  cyst  and  then  a  tympanitic 
note  will  be  given  to  the  i)ercussion  over  it. 

5.  Degenerative  Processes  Including  Malignancy. — ^The  following 
secondary  changes  may  take  place  in  an  ovarian  tumor,  although 


none  of  them  can  be  diagnosed  with  certainty.  On  account  of  the 
necessity  of  speedy  operation  inilications  of  malignancy  require 
special  attention,  however. 

(a)  Calcareous  degeneration. 

(6)  Fatty  degeneration. 

(c)  M>^oniatouB  degeneration. 

(fl)  Changes  in  the  Huid  eontrnts  from  Mraw  color — with  8|>ecific 
gra\Hty  of  from  1010  to  IO^jO — to  thick  or  semisolid,  of  various 
colors  and  consistencies. 

(e)  Malignant  degeneration.  Carcinoma,  sarcoma,  endothe- 
lioma, and  teratoma  are  the  malignant  processes  affecting  ovarian 
tumors.  Suspicion  of  malignity  attaches  to  double-sided  tumors. 
I.e.,  tumors  of  both  ovaries,  and  to  paitial  development  in  the 
broad  ligament.  A*?eites  is  common  in  the  case  of  malignant 
tumors,  and  Ls  apt  to  be  small  in  amount  except  in  the  late  stage's 
of  the  disease.  Malignant  tumors,  except  sarcoma,  are  most  apt 
to  occur  in  old  rather  than  in  young  women,  and  cachexia  is  found 
in  the  later  stages  only.  Early  edema  of  the  legs  in  the  case  of  small 
tumo!"s  is  said  to  be  a  sign  of  mahgnanc\\  When  the  disease  has 
attacked  the  surface  of  the  tumor  hardness  of  the  tissues  anfl  a 
nodular  feeling  by  both  aljdominal  and  vaginal  palpation  is  most 
charaet<»ristic.  The  noilules  or  lumps  may  i>e  large  or  small. 
The  surface  is  irregular.  It  should  not  be  forgotten  that  cancer 
of  the  ovaries  is  very  often  metastatic  and  that  the  primary  seat 
of  the  disease  should  Ix'  sought  in  the  stomach  or  intestine. 

6.  Rupture.^ — Rupture  of  an  ovarian  cyst  is  of  unusual  occurrence, 
especially  in  these  days  of  relatively  early  operation  on  women 
who  have  tumors.  In  the  older,  preaseptic  days,  when  tlie  danger 
of  operation  was  great,  many  cysts  ruptiu-ed  and  filled  again  or 
caused  peritonitis  as  it  happened  The  physician  and  also  the 
niu'se  should  rememlxT  that  a  thin-waDed  cyst  or  one  having  weak 
places  in  its  walls  iK'cause  of  degenerative  processes  may  Im?  rup- 
tured by  a  too  vigorous  bimanual  examination  or  by  preparations 
for  an  abdominal  o{>eration.  Both  of  these  accidents  have  occurred 
in  my  expf^'ii'nce.  In  the  case  of  a  mullilocular  cyst  only  one 
loculus  may  rupture  and  the  rupture  may  Ix^  into  the  main  cyst 
cavity,  into  anotlni'  ]o(*ulus,  or  into  any  one  of  the  following  struc- 
tures: peritoneal  cavity — most  frequent — and  bladder,  vagjna,  or 
rectum.    Rart^ly  rui>ture  has  occurred  into  the  small  intestine,  or 


320  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

Fallopian  tube,  and  very  rarely  through  the  abdommal  wall  or  into 
the  stomach.  The  causes  of  rupture  are,  degenerations  of  the  cyst 
wall;  papillomatous  growths  penetrating  the  wall;  torsion  of  the 
pedicle,  causing  hemorrhage  or  suppuration  in  the  cyst  with  in- 
creased tension ;  and  trauma,  such  as  blows  on  the  abdomen,  care- 
less handling,  already  referred  to,  or  contractions  of  the  abdominal 
walls  in  labor.  Parovarian  cysts  when  once  ruptured  may  not 
refill.  In  the  case  of  ovarian  cysts  the  wall  continues  to  secrete 
fluid  after  rupture  and  the  cyst  may  refill  or  the  fluid  may  be 
'poured  into  the  organ  into  which  the  openmg  has  been  made. 
If  the  fluid  is  clear  and  serous  it  may  cause  little  irritation  of  the 
peritoneum ;  if,  on  the  other  hand,  it  is  colloid  or  dermoid  in  char- 
acter it  is  apt  to  set  up  a  lively  peritonitis.  The  gravity  of  rupture 
depends  then,  in  large  measure,  on  the  character  of  the  cyst  con- 
tents. This  being  unknown,  the  complication  must  be  regarded 
as  serious  and  treated  by  inmiediate  operation,  for  rupture  of  an 
infected  cyst  into  the  peritoneal  cavity  is  usually  fatal. 

The  symptoms  are  severe  pain  in  the  abdomen,  faintness,  rapid 
pulse,  perhaps  subnormal  temperature.  Examination  shows  ab- 
sence of  the  tumor  and  free  fluid  in  the  peritoneum,  or  discharge  of 
fluid  from  bladder,  vagina,  or  rectum,  or  other  viscus.  If  only  one 
loculus  has  been  ruptured  the  tumor  wall  be  diminished  in  size 
only  by  so  much. 

7.  Association  with  Pregnancy. — Small  or  medium-sized  tumors 
are  more  often  found  in  association  with  pregnancy.  Because  of 
the  danger  of  rupture  and  torsion  of  the  pedicle,  the  diagnosis 
of  pregnancy  in  these  cases  is  of  the  greatest  importance.  In  the 
early  months  it  is  a  question  of  determining  the  presence  of  more 
than  one  growth  in  the  pelvis  or  a  tumor  on  each  side,  one  being  the 
uterus  and  the  other  the  ovarian  tumor.  The  signs  of  pregnancy 
are  referred  to  in  Chapter  XXII.,  p.  420.  If  physicians  would 
make  it  a  rule  to  examine  all  pregnant  women  under  their  care 
from  time  to  time  with  reference  to  the  detection  of  tumors  and 
other  abnormalities,  many  of  the  tragedies  of  the  puerperium 
would  be  avoided.  In  cas(*s  of  doubt  it  is  advisable  to  administer 
ether  in  order  to  make  a  diagnosis. 


PATIlOLOniC  AL  VARIETIES  OF  OVARLVN  TUMOR.S 


32  i 


I 


I 


'Diagnosis    of    thk    Different    Pathological    Varieties    op 

OVAKIAN   TUMOBS 

The  <liffcrcnt  kinds  of  ovarian  tuniom  according  to  their  patho- 
logical rhamet prist ics5  are  shown  in  tlie  lint  on  page  29L  Prognosis 
and  treatnit'nt  depend  in  a  measure  on  the  kintl  of  tumor  present; 
theR^fore,  certain  probabilitie^s  may  be  stated  sis  to  the  different 
tumors.  The  following  description  is  taken  with  few  changes 
from  Winter's^  **G>iiaekologi.schen  Diagnostik,"  p,  303. 

I*  Follicular  cysts  never  occur  largei*  than  a  base-l.>all.  They  arc 
unilocular,  have  thin  walls^  and  arc  not  tightly  distended,  so  that 
fluctuation  can  be  eheited  easily*  They  are  generally  unilati^ral 
and  do  not  cause  fjain. 

2*  Cysts  of  the  corpus  luteum  are  not  larger  than  a  base-bail;  they 
have  thick  walls,  and  are  unilateral. 

3,  Simple  cysts  have  tliin  wall^  and  tliin  fluid  contentsp  and  are 
differentiated  cUnically  from  follicular  cysts  only  by  their  greater 
size. 

4,  Multilocxilar  cysts  are  the  most  common  kind  of  ovarian 
tumors.  They  vary  m  hizq  from  verj^  small  to  enormoiLs.  In  the 
Ix^ginning  t?[Uch  a  tumor  is  roimd,  but  Ix'eome^  irregular  in  shape 
by  the  development  of  several  cysts  within  the  parent  cyst.  There- 
fore, the  surface  becomes  lobulated  and  in  some  eases  the  large 
and  small  daughter  cysts  can  Ix^  palliated.  The  consistency 
varies  according  to  the  fluid  contents.  Hard  portions  are  apt  to 
be  found  in  the  walls  where  there  has  been  no  cystic  degeneration. 
The  small  or  multiloeular  tumors  are  fairly  movable;  the  larger 
ones  are  hmite<l  in  motion  by  adhesions,  which  are  common, 
especially  to  the  omentum,  bowel,  and  abdominal  wall,  seldom  to 
the  uterus  or  other  iH'hie  organs.  These  tumors  are  usually  uni- 
lateral and  have  a  well-marked  pedicle.  Ascites  is  generally  absent ; 
when  presc*nt  it  is  in  small  amonut. 

5,  Proliferating  papillary  cysts  are  seldom  larger  than  a  man's 
head.  They  are  not  often  perfectly  round  in  shajX'  and  have  an 
uneven,  lumpy  surface.  In  the  situations  where  the  papillary 
masses  occur  the  consistency  is  not  so  fluid  as  elsewhere.  The 
tumors  are  ajxt  to  affect  Ijoth  ovaries — iloublc  tumor:  they  are  of 
intraligamentous  development,  at  least  on  one  side,  and  are  often 

21 


322  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

partially,  but  not  entirely,  in  the  broad  ligament.  When  the 
papillary  masses  have  pierced  the  wall  of  the  tumor  there  are 
metastases  in  different  parts  of  the  abdomen,  especially  in  Doug- 
las' cul-de-sac.    Ascites  is  common. 

6.  Primary  carcinoma,  when  small,  retains  the  form  of  the  ovary; 
when  large,  the  tumor  has  a  surface  that  is  very  rough  because  of 
knobs  and  excrescences.  Small  tumors  are  hard,  large  ones  are 
cystic  because  of  degenerative  processes  inside.  The  pedicle  is 
for  the  most  part  short,  and  the  tumor  may  be  intraligamentous. 
The  tumors  are  generally  double  and  ascites  is  commonly  present. 
Early  edema  of  the  legs  is  to  be  looked  for  in  the  case  of  small 
tumors,  and  cachexia  in  the  late  stages.  Metastases  occur  early. 
Secondary  carcinoma  attackmg  a  cyst  has  the  same  charact(*ristics. 

7.  Dermoids  are  seldom  larger  than  a  man's  head  and  most  often 
between  a  hen's  egg  and  a  Florida  orange  in  size.  They  are  round 
and  oval  in  shape  and  are  seldom  double,  having  for  contents 
thick  fluid,  fat,  bone,  and  hair;  fluctuation  is  not  marked.  Some- 
times bone  may  be  felt  in  the  wall  of  the  cyst,  and  often  there  are 
portions  of  solid  tissue  in  dermoid  cysts.  These  cysts  are  of  slow 
development  and  occur  most  often  in  young  persons.  Adhesioius 
are  common  and  occasionally  the  tumor  adheres  so  closely  to  the 
intestine  that  there  is  gas  in  the  tumor.  The  x-rays  may  show 
the  bone  in  a  tumor. 

8.  Teratomata  are  apt  to  be  the  size  of  a  man's  head  and  occur 
mostly  in  young  subjects.  Their  consistency  is  solid,  often  hard, 
and  they  may  contain  nodules  of  varying  consistency.  If  the 
tumor  is  malignant  there  are  metastases  and  ascites.  The  clinical 
diagnosis  can  seldom  be  made. 

9.  Fibroma  of  the  ovary  is  a  round  or  oval  tumor,  very  hard, 
with  smooth  surface  and  generally  unilateral.  It  may  be  as  large 
as  a  man's  head  and  ascites  is  usually  present.  Of  ton  cystic  cavi- 
ties develop  in  such  tumors,  and  the  ascites  does  not  return  after 
the  tumor  has  been  removed.  Fibroma  can  not  be  distinguished 
clinically  from  fibrosarcoma. 

10.  Sarcoma  of  the  ovary  occurs  sis  fibrosarcoma  (spindle-celled 
sarcoma)  and  as  round-celled  sarcoma.  The  former  is  generally 
double,  has  a  smooth  surface  and  a  hard  consistency,  and  ascites 
is  present.  It  is  benign,  and  no  metastases  are  formed.  The 
round-celled  sarcoma,  on  the  other  hand,  occurs  as  a  soft,  medullary 


PATHOLOGICAL  VARIETIES  OF  OVARIAN  TUMORS         323 

tumor  with  tolerably  smooth  surface.  It  is  generally  unilateral 
and  ascites  is  often  present  and  the  tumor  may  be  of  considerable 
size.  The  tumor  elements  perforate  the  surface  early  and  in- 
filtrate the  neighboring  organs,  especially  the  abdominal  cavity. 
II.  Peri-  and  endothelioma  have  the  same  characteristics  as 
round-celled  sarcoma. 


CHAPTER  XVIII 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  FALLOPIAN  TUBES 

Anatomy  and  age  changes,  p.  324. 

Congenital  Anomalies,  p.  32(5 :  Absence  of  the  tubes,  p.  326.  Accessory 
tubes  and  ostia,  p.  326.  Diverticula  from  the  tube,  p.  326.  Hernia  of  the 
tube,  p.  326.  Displacement  and  elongation  of  the  tube,  p.  326.  Cyst  of 
Morgagni,  p.  327. 

Salpingitis,  p.  327:  Acute,  p.  327.  Chronic,  p.  329.  Gonorrheal,  p.  330 
Tuberculous,  p.  330.  Actinomycotic,  p.  332.  Echinococcus  infection,  p 
332.     Syphilitic,  p.  332. 

Retention  tumors  (Sactosalpinx),  p.  332.  Pyosalpinx,  p.  332.  Hydro 
salpinx,  p.  333.     Hematosalpinx,  p.  334.     Diagnosis  of  Sactosalpinx,  p.  335 

Differential  diagnosis  of  Apjiendicitis  and  Salpingitis,  p.  336. 

New  Growths,  p.  337 :  Polypus,  p.  337.  Papilloma,  p.  337.  Embryoma 
p.  338.  Myoma  and  fibroma,  [).  338.  Fibromyxoma,  p.  338.  Carcinoma 
p.  338.     Sarcoma,  p.  339.     Chorioepithelioma,  p.  339. 

ANATOMY  AND  AGE  CHANGES 

The  Fallopian  tubes  are  (leveloptnl  from  the  portion  of  Miiller's 
ducts  lying  above  the  round  ligaments,  and  as  they  come  from  the 
same  structures  as  the  uterus  and  vagina  they  are  continuous  with 
these  organs  and  tluur  canals,  and  are  parts  of  one  long  tube, 
branching,  when  it  reaches  the  uterine  horns,  into  two  tubes.  (See 
Fig.  71,  page  198.) 

Each  tulx3  occupies  th(^  free  border  of  the  broad  ligament.  It 
has  an  average  length  of  four  inches  (10  centimeters)  but  may 
vary;  sonujtimes  one  tub(*  is  longer  than  its  fellow.  The  inner 
third  of  the  tub^  is  narrow  and  is  from  one-sixteenth  to  one-eighth 
inch  (2  to  4  millimeters)  in  diameter;  it  is  called  the  isthmus.  The 
outer  two-thirds  is  larger  in  diameter,  three-eighths  inch  (7  to  8 
millimet(Ts),  is  called  the  ampulla,  and  ends  in  the  infundibulujny 
or  trumpet-shaped  depression,  in  the  center  of  which  is  the  ostium 
alydominale  surroundcnl  by  the  fimhricv,  or  fringes.  These  fringes 
an^  (*xt(»nsions  of  the  reduj)licated  mucous  membrane  lining  the 
tube  and  are  of  uneven  length.     Running  from  the  abdominal 

324 


ANATOMY  AND  AGE  CHANGES 


325 


n^tiuni  to  l!iu  ovary  is  tiu*  luf>f)-ovarian  ligament,  traversal  by  a 
fun'ow  so  tliat  it  appears  to  Im^  a  Icmg  ftnil)riiL  Hiis  lypresents 
the  uppenriost  ]tortion  of  Miillcr^s  duct  that  has  hixm  opcnoil  out, 
liLsteacl  of  remaining!;  a^  a  flost'tl  tulx*.  The  tii)>c  is  cr^nvokitetl, 
tlie  isthmus  Is  directed  outward  and  j;Ughtly  upward,  while  the 
ampulla  arches  over  anil  descends,  so  that  the  infundiluikim  m 
direet-eil  toward  the  ovary  and  the  fimbria'  are  in  contact  with  that 
gland.     (See  Fig,  1 16,  p.  285.) 

The  lumen  of  the  tube  varies  from  the  diameter  of  a  bristle  at 
the  isthmus  to  a  fjuarter  of  an  inch  (some  5  niillimetei's)  in  the 
ampulla.  It  is  lined  with  nmcous  membrane^  and  covered  with 
columnar  ciliated  epithelium,  which  is  redupHcated  and  throwTi 
into  longitudinal  folds.  These  folds  become  thicker  as  they  a{> 
proac*h  the  infundibulum  an<l  on  the  alKlomiiial  side  of  the  ostium 
are  continuous  with  the  finJbriu^  The  tuk>c  is  composed  of  un- 
striptnl  iiiuselt*  filx^r,  continuous  with  tliat  of  the  uterus,  and  ar- 
rangeil  in  an  outer  longitudinal  layer  and  an  inner  circular  layer. 
Outside  the  longituchnal  layer  is  loose  connective  tissue  bc^tweeii 
it  and  the  {jt^ritoneum,  which  covers  two-thirds  of  the  circumfer- 
ence of  the  tulx^  and  is  terminated  by  a  sharp  t^dge  at  the  ostium 
alMlominalt\ 

The  functi^m  of  the  tutjes  is  to  carry  the  ova  to  the  uterus.  It 
has  been  shown  by  Hofmc^ier  and  Mandl  (J.  Wliitridge  Williams, 
**ChTiecology  and  Alxlominal  Surgery,"  Kelly  and  Noble,  Vol.  II  , 
p.  132)  that  there  is  a  current  of  fluid  from  the  {>eritoneum,  or 
secretion  from  the  tubal  mucosa,  jiromoted  by  the  eilia  of  the  tuljal 
epithehal  cells,  from  the  ablominal  ostium  of  the  tubc^  to  the 
internal  o*;  of  the  uterus.  It  has  been  proved  by  experiments  on 
animals  and  a  few  ol]»servations  on  hmnan  l>eings  that  a  few  hours 
after  coitus  spermatozoa  can  lie  found  in  the  outer  portions  of  the 
tMlx\s  and  even  on  tht^  ovaries,  so  that  it  wouhl  ap|*ear  that  the 
siM^rmatozoa  get  into  the  tubes  in  spite  of  the  current  against  them, 
and  that  the  tuln'  is  the  rmrmal  place  of  inipregnaiion  ratlier  than 
the  uterus.  Under  normal  conditions  the  fertilizcnl  ovum  is  passfnl 
along  by  the  cilia  to  ihr  uterus  where  it  l>ecomes  end>e(lded  in  the 
uterine  mucosa.  Under  aluiormal  conditions  it  is  arrested  in  the 
tulx^  and  a  tuba!  pregnancy  results. 

At  the  menopause  the  Fallo])ian  tubes  atrophy,  becoming  shorter 
and  narrower  and  the  ejnthelial  elements  disappear,  so  that  in  the 


326  DISEASES  OF  THE  FALLOPIAN  TUBES 

old  woman  they  arc  nothing  but  slender  cords,  often  having  no 
lumen.     (See  Fig.  119,  p.  289.) 

CONGENITAL  ANOMALIES 

Absence. — Complete  absence  of  both  tubes  is  exceedingly  rare 
and  occurs  only  in  connection  with  failure  or  rudimentary  develoi>- 
ment  of  the  uterus.  Absence  of  one  tube  is  found  in  cases  of  failure 
of  development  of  the  corresponding  uterine  horn.  Partial  de- 
velopment of  the  tube  is  more  comman  than  complete  absence,  the 
tube  bemg  represented  by  a  narrow,  impervious  cord,  or  a  portion 
of  the  tube  only  may  be  implicated,  and  the  isthmus  may  be  normal 
while  the  ampulla  is  undeveloped  or  atypical,  or  vice  versa.  The 
diagnosis  can  not  be  made  without  an  abdominal  operation. 

Accessory  tubes  have  been  described  not  infrequently.  Probably 
many  of  them  are  not  true  cases  of  extra  tubes  but  accessory  ostia, 
a  much  more  common  condition.  Three  reporters  at  least  have 
given  instances  of  true  double  tubes,  and  Nagel  (Veit's  "  Handbuch," 
Bd.  I.)  found  a  double  Miillerian  duct  in  a  human  embryo. 

Accessory  ampullae  communicate  with  the  main  lumen  of  the 
tube,  usually  entering  near  the  attachment  of  the  mesosalpinx. 
Each  has  its  own  infundibulum  and  fimbriae.  As  many  as  six 
accessory  ostia  have  been  reported;  one  or  two  are  not  uncommon. 

Diverticula  of  the  walls  of  the  tube  appearing  as  hemiae  occur 
occasionally,  and,  like  the  supernumerary  ostia,  are  of  importance 
because  they  may  be  lodging-places  for  fertilized  ova,  and  thus  a 
cause  of  tubal  pregnancy.  This  anomaly,  as  also  the  preceding, 
can  not  be  diagnosed  except  at  operation. 

Hernia. — The  tube  is  found  sometimes  with  the  ovary  in  a  hernial 
sac.  Such  hemiae  are  generally  of  the  inguinal  variety  and  uni- 
lateral. The  condition  is  not  susceptible  of  diagnosis  before  opera- 
tion. 

Displacement  and  elongation  of  the  tube  may  be  congenital  or 
acquired.  The  tube  is  displaced  to  a  greater  or  less  degree  with 
displacements  of  the  ovary  and  uterus,  and  also,  in  the  case  of  large 
ovarian  tumors  and  large  tumors  of  the  broad  ligament,  it  is  both 
displaced  and  elongated.  In  pregnancy  it  becomes  lengthened 
enormously  as  the  uterus  approaches  its  size  at  full  term  and  after 
labor  the  tube  involutes  with  the  utcTiLs  to  regain  its  normal  size. 


S.AXPmOITIS 


327 


Sometimes,  where  the  conditions  for  examination  are  most 
favoral^le,  i.e,,  very  tliin  abdominal  walls  or  separation  of  the  recti, 
it  18  potssible  to  pa!i)att'  an  ehmgated  Fallopian  tubi*  coursing  over 
a  timior  or  at  the  side  of  a  jjregnant  uterus.  Generally  the  iliagnosi^^ 
can  not  be  made. 

The  cyst  or  hydatid  of  Morgagni  is  a  .small  cyst  rarely  larger  tlian 
a  pea,  attached  l)y  a  stalk  one  to  one  and  a  half  inches  (some  2  to  6 
centinieterH)  long,  to  the  findjriie  or  to  the  tulxi  itself.  It  is  en- 
tirely harmlesss  and  ha  no  clinical  importance. 


SALPINGITIS 


Salpingitis  is  the  chief  disease  of  the  Fallopian  tubes  of  interest 
to  the  practising  physician. 

The  classifieation  of  salpingitis  from  an  etiological  standpoint  is 
difficult  becaase  it  is  impossible  to  di.stinguish  the  different  sorts  of 
bacteria  tliat  serve  as  excitmg  causes.  The  streptococcus  and  the 
gonococcus  are  the  two  most  important  microorganisms.  It  ia 
probable  that  in  those  cases  where  the  pus  in  the  tubes  is  ster- 
ile the  inflammation  was  originally  of  streptococcic  origin  but 
that  the  organism  has  ditnl  out,  These  organisms  are  transmitted 
to  the  tubes  through  the  uterus,  an  endometritis  being  an  almost 
invariable  precursor  of  a  salpingitis.  The  tulx-rcle  bacillus  is  a  not 
infrequent  cau^e  of  salpingitis,  and  rare  causes  are  actinomycosis, 
ecliinoeoccus  tUsease,  and  sji>liilis.  Hennirrhagic  salpingitis  may 
accompany  the  exanthemata,  and  there  is  a  mild  catarrhal  form  of 
salphigitis  and  fuTisalpingitis  of  imknown  origin  tliat  occurs  as  a 
compUcation  of  uterine  tumors. 

It  is  possible  for  fluiils  injected  into  the  uttTUs  to  pass  into  the 

tuljes,  especially   when   the   tubes  have   Ix»en   hypertrophied   by 

pregnancy  and  when  the  normal  tonus  is  not  present^  and  thus  set 

up  a  salj>ingitis,  though  this  is  an  aeatiemic  affair.     The  hnnen  of 

the  isthmus  of  the  tube  ia  very  small  and  the  irritation  caused  by 

foreign  fluids  Si*ts  up  a  contraction  of  the  circular  fibers  so  that  it  is 

_     seldom  that  fluid  can  be  madi'  to  [>ass  through, 

I        Salpingitis  may  \}q  divided  cliiucally  mto  acute  and  chronic, 

■        Acute  Salpingitis, — Pathology. — In  the  case  of  catarrhal  sdpi'mjiti^f 

m    in  the  c^rly  stages  of  an  acute  attack  the  mucou>s  membrane  is 


328  DISE.\SES  OF  THE  FALLOPIAN  TUBES 

swollen  so  that  the  redundant  foI(k  fill  the  lumen  of  the  tube.  The 
muscular  and  peritoneal  coats  are  involved  to  a  greater  or  less 
degree  and  the  entire  tube  Is  re<ldened;  the  tissues  are  edematous 
and  soft.  According  to  the  character  of  the  infecting  agent  the 
inflammator\'  process  extends  or  does  not  to  the  ovary  and  neigh- 
boring structures  of  the  peritoneum  through  the  ostium  abdom- 
inale.  Apparently  sometimes  the  swelUng  of  the  mucosa  in  the 
tube  is  sufficient  to  close  the  ostium  and^  the  disease  is  limited  to 
the  tube  itself.  In  the  tube  accumulates  a  certain  amount  of  serous 
fluid,  drainage  into  the  uterus  being  interfered  with  by  the  swelling 
of  the  mucosa  in  a  very  small  canal. 

In  the  ca.*5e  of  pundeni  salpingitis  all  the  processes  are  intensified. 
The  mucous  membrane  is  more  swollen  and  injected;  the  entire 
tube  is  much  enlarged  and  there  is  pus  in  its  canal.  The  peritoneal 
covering  of  the  tube  is  involved,  and,  either  by  direct  extension  of 
the  inflammation  through  the  wall  of  the  tube,  or  because  of  the 
action  of  the  pus  that  escai)es  from  the  ostium  of  the  tube,  ad- 
hesions of  the  ampulla  to  surrounding  structures, — bowel,  omen- 
tum, bladder,  or  uterus,  are  formed.  The  mesosalpinx  and  broad 
ligament  are  infiltrated  so  that  they  have  a  board-like  feeling. 

Symptoms. — The  symptoms  of  acute  caiarrhal  salpingitis  are  so 
slight  that  they  are  overshadowed  by  the  symptoms  of  the  co- 
existing endometritis.  (See  page  174.)  The  symptoms  of  acute 
purulent  salpingitis^  on  the  other  hand,  are  often  severe,  consisting 
of  abdominal  pain,  fever,  rapid  pulse,  uterine  hemorrhage,  dysuria 
and  painful  defecation,  and  purulent  vaginal  discharge.  Accord- 
ing to  the  amount  of  localized  peritonitis  are  the  symptoms  more 
urgent.  Where  the  inf(»ction  involves  the  ovary  and  a  tubo- 
ovarian  abscess  results  the  symptoms  and  signs  are  those  of  pelvic 
abscess.     (See  page  193.) 

Diagnosis. — The  history  is  that  of  endometritis  (see  page  174) 
and  preceding  infection.  In  the  catarrlial  form  palpation  by  the 
bimanual  touch  may  reveal  tenderness  of  the  tube,  but  this  is  a 
fine  point  in  diagnosis.  In  the  purulent  form,  not  only  tenderness 
but  thickening  of  the  tube  may  be  evident.  It  is  especially  to  be 
cautioned  that  the  utmost  gentleness  be  used  because  of  the  danger 
of  expressing  pus  from  the  ostium  of  the  tube  into  the  peritoneal 
cavity. 

Evidences  of  endometritis  are  also  present.    If  there  is  much 


SALPINGITIS 


329 


distention  of  the  tube  in  the  subacute  stage  the  tute  may  be  nnukt 
out  as  a  sausage-,  €lul>-,  or  rctort-shapeil  botly,  and  it  is  apt  tu  Ix' 
in  the  cul-de-sac  of  Douglas.  (See  Pyosalpinx.)  Acute  purulent 
salpinp:iti8  is  a  very  coninion  affection  and  the  attempt  should  be 
made  to  diapK>8e  the  <Hsea.se  early  in  its  course. 

Chronic  Salpingitis. — Pathology.— Chromv  stdjiingitis  results  from 
an  acute  sal|migitis.  The  tulx^  h  usually  closely  adherent  to  the 
ovary  and  surrounding  structures;  it  is  ajit  to  be  in  the  eul-tle-sac 
of  Douglas;  it  shows  markeil  convolutions  and  twists.  The  walls 
of  the  tube  are  generally  thickcnetl  and  indurate<l.  Sometimes 
the  thickening  is  in  the  isthmus,  and  at  others  in  the  ampulla. 
Now  and  then  one  finds  nodules  the  size  of  a  small  j>ea  in  the  struc- 
ture of  the  wall  of  a  tulx?  (salpingitis  nodosa),  these  being  found 
generally  in  the  isthmus.  On  section  they  show  a  dense  fil)ra- 
muscular  Mructure  containing  glan<llike  sjjaces,  which  sometimes 
represent  the  lumen  of  the  tube.  Tubes  containing  these  nodes  are 
apt  to  be  impervnous.  The  condition  is  not  to  be  confuscil  with 
nmhdar  tuberculosis  of  the  tul>e. 

The  ostium  of  the  tutx*  is  commonly  closed  by  peritonitic  adhe- 
sions or  exudate  in  cases  of  chronic  purulent  salpingitis,  but  otivn 
on  separating  the  adhesions  it  will  Ix^  found  that  the  fimbriirai'e 
free  and  the  ostium  is  patent.  It  is  probable  that  these  are  the 
cases  in  wdiich,  upon  the  subsidence  of  the  inflammation  and  the 
absorption  of  the  exudate  in  the  jK^ritoneum,  the  ostia  become 
pervious  again.  In  many  cases,  especially  tliose  due  to  gonococcus 
infection,  the  fimbria' arc  found  adherent  and  there  is  true  occlusion 
of  the  ostium. 

In  the  case  of  chronic  salpingitis  infection  from  the  tube  may 
be  transmitted  to  the  ovary ^  antl  a  tu!>o-ovarian  cyst  or  tub^v 
ovarian  abscess  may  result,  or  the  process  may  be  linuteil  to  the 
tube,  salpingitis  proper. 

Symptom*^  and  Diagnoms, — The  sym]>toms  an*  |>ains  in  flu*  gmins, 
a  sense  of  weight  in  the  pelvis,  exacerbations  of  h*ver,  irregular- 
ity of  menstruation,  dysmenorrhea,  and  vaginal  ilischarge.  The 
I  diagnosis  is  made  by  palpating  enlarged  tulx^s,  by  the  presence 
of  preceding  and  coinci<lent  endometritis,  and  by  symptoms  of 
I>ain  anrl  fev<»r  not  accounted  for  by  the  enttometritis. 

Salpingitis  due  to  the  streptococcus  is  k^ss  apt  to  affect  both 
tubes  than  is  the  gonorrheal  variety. 


330  DISEASES  OF  THE  FALLOPIAN  TUBES 

Gonorrheal  Salpingitis. — As  a  rule  it  is  a  long  time,  months  or 
years,  before  the  gonococci  of  an  endometritis  reach  the  tubes, 
although  they  have  been  found  in  the  tubes  within  two  weeks 
after  the  initial  infection;  therefore  the  disease  is  generally  de- 
scribed as  being  subacute  or  chronic  from  the  start. 

The  disease  is  usually  bilateral  and  may  be  ushered  in  by  a  chill, 
fever,  and  local  tenderness  and  pain.  In  the  more  chronic  stages 
the  amount  of  tenderness  is  variable  and  may  be  wanting,  th(?re 
is  generally  no  fever,  and  the  patient  may  be  in  fair  health 
except  for  anemia  and  debility;  but  during  the  menstrual 
periods  there  are  dysmenorrhea,  local  tenderness,  irregularities 
of  menstruation,  and  increased  vaginal  discharge  as  troublesome 
symptoms.  Acute  attacks  of  inflammation  are  apt  to  occur  in 
the  history  of  chronic  gonorrheal  salpingitis  and  whenever  a 
drop  of  pus  escapes  into  the  peritoneal  cavity  there  is  inflam- 
matory reaction. 

As  previously  stated,  the  ostia  of  the  tubes  are  more  apt  to  be 
closed  by  gonorrheal  than  by  streptococcic  inflammation,  thus 
accounting  for  the  sterility  of  prostitutes. 

Diagnosis. — ^Unless  the  gonococci  can  be  found  in  the  discharges 
from  the  uterus  there  is  no  way  of  distinguishing  this  form  of 
salpingitis  from  any  other.  The  probabilities  may  point  in  this 
direction  from  a  history  of  gonococcus  infection,  from  the  occur- 
rence of  gonorrheal  joint  affections,  or  from  evidences  of  past 
inflammation  in  the  vaginal  or  inguinal  glands. 

Tuberculous  Salpingitis. — The  Fallopian  tube  is  the  most  frequent 
site  of  genital  tuberculosis  in  the  female.  Where  careful  routine 
microscopical  investigations  have  been  made  of  all  the  clinical 
material  furnished  by  the  operating-rooms  of  hospitals  it  has  been 
found  that  from  five  to  ten  per  cent  of  all  the  inflammatory  aflfec- 
tions  of  the  tulx^s  are  tuberculous.  Without  painstaking  investiga- 
tions it  is  impossible  often  to  distinguish  tuberculous  from  simple 
salpingitis. 

The  disease  may  be  primary  in  the  tubes  (it  is  generally  bilateral) 
or  secondary  to  a  lesion  or  lesions  at  a  distance,  as  in  the  lungs,  or 
in  a  contiguous  organ,  such  as  a  tuberculous  ulcer  of  the  intestine. 
The  tubercle  bacillus  may  come  to  the  tube  from  the  va^a  by 
way  of  the  uterus,  or  from  the  blood  current.  The  infection  may 
be  limited  to  the  tubes,  or  both  ut(Tus  and  tubes  are  involved. 


SALPINOITIS 


331 


It  is  possible,  and  not  a  xt^ry  uncommon  hapjiening^  for  the  gono- 
C0CCU9  to  be  aissociated  with  the  tiibcvrcle  tjacillas, 

Palhology. — TuU^reulmis  of  the  tuljes  appt^an^  m  tliree  forms, 
miliary^  caseom^  anil  fibrous.  The  appearances  of  tlie  tube  vary 
according  as  the  disease  began  in  the  nuicous  membrane  linnig 
its  cavity  or  in  the  peritoneal  coat.  The  tube  may  te  atrophied 
or  much  enlarged  and  tortuous  and  a  part  or  the  entire  tulxr  may 
l:>e  affected.  Mieroseopically  tuljerculous  nodules  are  fouod.  These 
consist  of  a  central  giant  ceU  Burrounded  by  epithelioid  cells  and 
an  outer  zone  of  sriiall  round  cells.  Caseous  foci  arc  common  and 
the  folds  of  the  mucosa  are  thickened  and  adherent.  The  lumen 
of  the  tube  may  be  closed  by  a  hyperplastic  process  affecting  the 
mucosa  just  as  ir  the  swelUng  which  accompanies  infections  by 


FiQ.   1 36, ^Tuberculous  Salpingitis.     (Dudley.) 

other  organisms.     The  disease  generally  is  progressive,  but  may 
Ik*  arrer^ted,  the  tufx*  being  rejiresent^d  in  such  cases  by  a  thin, 
irniX'r\Hous,  fibrous  cord.    If  the  disease  progi*esses  one  exj>ects  to 
find  tuberculosis  of  the  pi^ritoneum. 
K  Diaffnosis, — Tul^t^rculous  salpingitis  is  seldom  seen  in  an  early 

m      stege  when  the   diagnoi^is   can   he  only  that   of  salphigitis,    A 

■  tuberculous  history  or  tuberculosis  elsewhere  in  the  body  leads  one 
I       to  suspect  the  etiological  significance  of  a  salpingitis  and  some- 

■  times  in  the  later  stages  fluid  in  the  ix'ritoneum  calls  attention  io 
I       tuberculosis.    Pyrexia,  recurring  every  evening  and  disappearing 


332  DISEASES  OF  THE  FALLOPIAN  TUBES 

every  morning,  loss  of  weight  and  strength,  rapid  pulse,  sweating, 
particularly  at  night,  are  symptoms  of  tuberculosis. 

Actinomycotic  salpingitis  is  secondary  to  actinomycosis  elsewhere, 
besides  being  very  rare.  The  tubes  are  convert^nl  into  abscesses 
in  which  the  characteristic  yellow  or  brownish-black,  sago-like 
granules  are  readily  recognized.  Under  the  microscope  the  acti- 
nomyces  is  recognized  in  the  characteristic  granulation   tissue. 

Echinococcus  infection  is  extremely  rare  also,  and  is  secondary  to 
hydatid  disease  in  the  broad  ligament  or  elsewhere  in  the  pelvis. 
Sometimes,  but  not  always,  pelvic  hydatids  are  secondary  to 
hydatid  disease  of  the  liver  or  other  abdominal  organ.  Cases 
have  been  reported  of  tub(^s  enormously  distended  by  hydatids. 
The  diagnosis  would  rest  on  the  discovery  of  the  disease  in  some 
neighboring  organ  or  the  passage  of  cysts  from  the  vagina,  rectum, 
or  bladder. 

Syphilitic  salpingitis  must  be  regarded  as  a  very  rare  disease. 
It  has  been  found  in  the  new-bom  and  extremely  rarely  in  the 
adult.  The  tubes  contain  miliary  gummata  m  their  walls,  and  the 
folds  of  the  mucosa  are  adherent.  In  one  case  in  an  adult,  gummata 
the  size  of  hazelnuts  were  found.  The  diagnosis  is  made  probable 
by  finding  evidences  of  syphilis  in  other  situations  in  the  body, 
by  the  history  of  syphilis,  and  by  the  presence  of  an  enlarged  tube. 


RETENTION  TUMORS   OF   THE   TUBE,  OR   SACTOSALPINX 

Pyosalpinx  is  a  Fallopian  tube  distendcnl  with  pus.  The  tube 
varices  in  size  and  shape.  With  moderate  distention  it  is  club- 
shaped,  having  a  numb(T  of  convolutions;  with  more  distention  it 
is  retort-shaped  with  the  stem  of  the  retort  at  the  uterine  horn; 
here  the  convolutions  are  more  or  less  eliminated.  With  extreme 
distention  the  tuln*  becomes  an  oval  sac.  These  large  tubes  arc* 
uncommon.  The*  largest  ones  I  remembiT  having  met  were  in  the 
case  of  a  woman  twenty-thn^e  yeai*s  old,  upon  whom  Dr.  Clement 
Cleveland  operated  with  my  assistance  January  20,  1890.  The 
patient  had  Ixvn  married  one  year  and  had  not  been  pregnant. 
She  had  v(Ty  few  symptoms.  The  right  tulxi  measured  six  inches 
in  length,  and  three  inches  in  diameter  at  its  outer  end,  and  one 
and  three-fourths  inches  at  its  inner  end.     Three  inches  of  the 


RETENTION  TUMORS  OF  THE  TUBE 


333 


isthmian  end  of  tlir  tiilx'  wrrt'  ntjt  uidargril.  Thi*s  tulx*  hatl  t'om- 
paratively  few  mlhcisions  alx)ut  it.  The  left  tulx>  inesLsurcil  four 
ineht^s  in  length,  and  ttnu'c  inehei?  in  diaraeter,  and  the  surrounding 
a<lhesionH  were  iiensc*  Eaeh  wfni  ovoid  in  shape  and  showed  no 
convolutions. 

Ab  a  rule  a  pus  tuk^  is  surrounded  by  adhesions,  bcK^ause  its 
peritoneal  surfaee  is  eiiveloprd  hi  an  inflanunatory  niernbnine. 
The  pus  is  sterile  hi  over  half  of  all  cas(*s.  This  fact  is  explainett  by 
the  dymg  out  of  the  microorganisms  which  have  caused  the  inflam- 
mation and  arc*  always  to  be  found  in  the  aeute  and  subacute  cases. 
The  walls  of  a  j-jyosalprnx  are  generally  thick,  1  jut  they  may  te  thin. 


F 1 G .   1 37 . — Py osalpin jE . 


In  the  older  eases  tln^  epithelial  lining  of  the  tube  has  been  replacetl 
by  granulation  tissue.  Ru|>ture  uito  the  peritoneal  ca\ity  is  an 
aeciileiit  which  has  wcurnnl,  although  not  very  commonly.  Q  W. 
Bonnoy  {Sunjery,  (hpiecokMjy,  and  Obs-tetrks^  Nov.,  VMJ,  p.  M2) 
■  collected  forty-five  case-s,  including  the  cas*:»s  from  the  literature 
an<l  a  case  of  his  own.  In  most  instances  there  was  no  as.sigiiable 
cause  for  tin*  rupture.  Whenever  hifection  has  set  up  an  absccMs 
of  the  ovary  as  well  as  a  pyosali.nnx  the  condition  is  knov^Ti  as  a 
tuffO-ovarian  ahscess.  This  has  been  described  under  Pelvic  Abscess. 
(See  Cliaiiter  XII,  inige  193.) 

The  diagnosis  of  jiyos^ilpinx  will  Ix*  considered  with  the  diag- 
noisis  of  hydrosalpinx  and  liemato.s;xl]/mx, 

Hydro^pinx  is  an  accumulation  of  serous  fluid  in  the  tube.     It 


DISE^VHES  OF  THE  FALLOPIAN  TUBES 

presupposos  complete  closure  of  the  ostium  abdominale,  but  not 
necessarily  the  lumen  of  the  isthmus  of  the  tube,  and  is  the  result 
of  a  pref'xisting  salpingitis^.  In  intemiitlmt  hydrosalpinx  there  is  i 
a  temporary  obstruction  to  the  uterine  outlet  of  the  tube  caused 
by  kinks  in  the  isthtim^,  that  is,  a  mechanical  stenosis  exists.  In 
such  cases  there  is  a  periodic  discharge  of  watery  fluid  tlirough  the 
utc^rus.  The  shapes  of  tulx\s,  the  seat  of  hydrosalpinx,  are  the  same 
as  those  of  pyosalpinx,  but  the  walls  arc  thinner  and  on  micro- 
scopic examination  are  seen  to  l>e  practically  normal,  except  in 
the  case  of  follicular  hydrosalpinx^  in  which  there  are  evidences 


/\htmal  i 


Fig,  138. — Hydrosalpinx,  Two-thirds  Actual  Size,    ^Author's  Caae). 


of  endosalplngitis.  Hydrosalpinx  is  seldom  larger  than  a  Bartlett 
jK*ar,  although  cases  have  lx*en  reported  the  size  of  a  child's  head. 
Tlie  ampulla  of  the  tube  is  cUlated  with  fluid  more  often  than  the 
isthmus.  If  an  ovarian  cyst  connects  with  a  distended  tube  by 
an  adventitious  openmg  not  the  ostium  abdominale.,  the  condition 
is  known  as  a  iubo-ovarian  cys^t.  These  cysts  are  by  no  means 
vineommon,  and  can  not  be  distinguished  clinically  from  hydrosal- 
pinx,  except  m  those  rare  cases  of  hydro  salpinx  in  wliich  the  normal 
ovary  can  b?  palpated  by  bimanual  toii(Oi. 

oatosalpinz  is  a  Fallopian  tulx^  tlistended  with  fluid  bloocL 
di«ge  occurring  into  a  hydrosalpinx  forms  a  hematosalpinx, 
iw  believed  that  a  majority  of  cases  of  hematosalpinx  are 


RETENTION  TUMORS  OF  THE  TUBE 


335 


the  result  of  tubal  pregnancy  and  incomplete  abortion.  (Sec 
Tubal  Pregnancy.)  Hematosalpinx  presupposes  clo.siue  of  the 
ends  of  the  tubt*  just  as  in  the  case  of  pyosalpinx  and  hydi'osalpinx. 
Hemorrhage  into  the  tube  may  take  place  as  a  n:\sult  of  torsion  of 
the  tutx'  and  it  occm^s  as  a  complication  of  fibroids  of  th<*  uterus. 
It  i.s  found  also  in  cases  of  imperforate  hymen  with  accumulation 
of  menstrual  blood  in  the  uterus  {hematometra). 

Hematosalpinx  resembles  hydrosalpiiLx  as  to  size  and  shape^ 
but  is  of  a  dark  reddish-browii  color.     The  walls  are  tlnek,  but 


-Ufk 


mus    Oj 


:flube 


Fig,  139. — HetiiatostilpirLx^  Actual   8ize,   Causc^l  by   Acute  Torsioii  of    Right 
Tube.   Twist  o(  Two  Turns  to  tlie  Eight  at  tiie  Istlunya.    (Author's  Case). 

friable,  and  covered  by  adhesions.  On  microscopic  examination 
it  is  seen  that  the  mucosa  is  tlegenerated  and  destroyed,  the  museu- 
lar  tissue  is  swollen  and  infiltrated,  while  the  peritoneal  coat  shows 
thrombosed  vessels  and  deposits  of  blood  pignient. 


Diagnosis  of  Sactosalpinx 

The  diagnosis  of  pro,  hydro-,  and  hematosalpinx  rest^  on  the 
determination  by  palpation  of  a  tumor  of  the  shape  of  a  dUat(d 
tube  connected  with,  but  not  a  part  of  the  uterus.  If  the  noimal 
ovary  can  be  disiinguislird  se|)arat</  from  the  tumor  so  much  the 
bf*tter.  In  the  cas*\s  whei'e  the  tulx^  is  not  very  large  the  charac- 
teristic  sliai>e— ^lub-ahat>tHl,  pyriforni,  or   retort-shaped — can   be 


336  DISEASES  OF  THE  FALLOPAN  TUBES 

made  out  with  clearm»ss.  Also  in  these  cases  the  isthmus  of  the 
tube  comiecting  the  tumor  with  the  uterine  horn  may  be  palpated. 
With  the  larger  tubes  no  characteristic  shape  can  be  learned  by 
palpation.  If  both  tubes  are  enlarged  it  is  a  strong  diagnostic 
ix)int  in  favor  of  retention  tumors  because  these  are  generally 
bilateral. 

Pelvic  peritonitis  with  adhesions  is  an  almost  universal  accom- 
paniment of  these  tumors,  therefore  they  are  more  or  less  fixed. 
There  is  no  means  of  knowing  previous  to  operation  the  contents 
of  a  dilated  tube,  whether  pus,  serum,  or  blood.  Aspiration  Js 
not  justifiable  because  by  puncturing  the  tumor  its  contents  may 
contaminate  the  peritoneum,  thus  complicating  needlessly  an 
o[)eration  for  removal,  which  is  indicated  in  all  cases. 

The  diagnosis  of  rupture  of  a  retention  tumor  is  the  same  as 
that  of  rupture  of  an  ovarian  tumor  (see  page  319). 

Torsion  to  the  point  of  strangulation  is  evidenced  by  acute 
stal^bing  abdominal  pain,  vomiting,  and  the  signs  of  a  tender 
tumor  in  the  situation  of  the  tube.  Torsion  without  stran- 
gulation has  been  reported  in  only  three  cases.  Storer  in  1906 
(M.  Storer,  Boston  Med.  and  Surg,  Jour.,  March  15,  1906,  page 
285)  r(»ported  a  case  of  bilateral  torsion  and  collected  sixty-two 
cases  of  torsion  of  the  tube  in  the  literature  since  Bland-Sutton 
first  called  attention  to  the  condition  in  1890. 

DiFFEIlENTIAL  DIAGNOSIS  BETWEEN  SALPINOmS  AND  APPENDICITIS 

Right-sided  salpingitis  is  often  mistaken  for  appendicitis.  It 
should  Ixi  remcmbcTcd  that  the  two  affections  may  co-exist, 
and  hi  this  case  which  was  in  the  beginning  the  exciting  cause  and 
whi(rh  is  tluj  chief  factor  at  the  present  time,  are  shown  by  the  clinical 
history  of  the  onset  of  the  attack.  Acute  salpingitis  is  usually 
f)recedo(l  by  endometritis,  by  a  vaginal  discharge,  and  by  menstrual 
disturbanc(*s,  oft(»n  by  dysmenorrhea.  In  the  case  of  appendicitis 
th(T(»  is  a  history  of  digestive  disturbances,  of  irregularity  of  the 
bowels,  or  of  previous  attacks  of  pain  in  the  right  side.  Rovsing 
has  made  us(^  of  a  method  of  reproducing  the  pain  of  appendicitis 
that  is  of  value  sometimes  in  the  differential  diagnosis.  He  strokes 
the  (l(»sc(»n(ling  colon  from  Mow  upward,  and  the  transverse  colon 
from  left  to  right,  thus  forcing  gas  back  mto  the  cecum  and  appen- 


dix,  distending  these  structures  and  reproilueing  a  pain  siniilar  to 
that  from  which  the  patient  has  FufferetU 

In  salpingitis  the  pain  is  more  steady,  less  intense,  and  radiates 
into  tlie  pelvis,  while  in  ap|>endiciiis  it  is  rolieky  ajid  mow  grneraL 

Dr.  Rotert  T.  Morris  (Jour.  Amer,  Med,  Asso,,  Jarniary  25,  1908, 
Vol.  L.,  page  278)  1ms  dirc^cted  attention  to  two  points  of  tenderness, 
eallcMl  Morris^  pom/.%  which  he  eonsiders  of  great  assistance  in 
distinguishing  t:/etween  elu'onic  saljiingitis  and  ehronie  appen- 
dicitis. One  point  is  situated  one  and  a  half  inches  from  the 
umbilicus  on  a  line  (bawn  from  the  umljilicus  to  one  anterior 
sujxTior  spinous  proeesss  of  the  ilium,  and  the  otiier  {>oint  is  in  a 
siniilar  situation  on  the  opposite  side.  These  [loints  are  approxi- 
mately over  the  hmibar  l>Tnph  glands  wiiich  receive  the  Ipnph  ves- 
st^ls  from  the  Fallopian  tulx-s,  ovaries,  uterus,  and  hroatl  ligaments, 
and  also  from  tlie  appendix.  McBurney's  {>oint  is  on  this  same 
line  on  the  right  side  one  and  a  half  inches  from  the  spinous  process. 
The  right  Morris'  point  is  tender  on  pres^sure  in  the  ease  of  chronic 
apiML'ndicitis  not  involving  the  Fallopian  tulx',  sometimes  even 
when  McBuraey's  point  is  not  tender.  In  the  ease  of  salpingitis 
either  unilateral  or  bilateral  l>oth  Morris^  jjoints  are  tender.  Several 
physicians  have  reported  satisfactory  results  from  the  use  of  this 
means  of  diagnosis  ami  it  may  l>e  regarded  as  an  accessory  to  other 
methods  of  diagnosis  in  chroni<*  cases. 


NEW  GROWTHS 


Primary  new  growths  of  tlie  Falltipian  tubers  are  relatively  rare. 
They  originate  in  the  nuieosii,  or  in  the  walls  of  the  tube,  and  are 
benign  or  malignant.  The  Ix-nign  growths  are,  polypus,  papilloma, 
erabryoraa,  njyoma  and  fibroma,  and  fibromyxoma.  T!ie  malig- 
nant groTi^'ths  are  carcinoma,  sarcoma,  and  clKjrioei^itlu^ioma. 
Polypus  of  the  mucosa  is  rare.  It  consists  of  simiile  inilanmiatory 
thickening  of  the  mucous  membrane  or  a  polypus  similar  to  a 
uterinf^  lJoIy[>us  originating  from  placental  tissue  left  attached  to 
the  tubal  wall  by  a  tubal  pregnancy. 

Papilloma  is  thought  to  be  a  result  of  an  old  salpingitis  rather 
ft  than  a  neoplasm  propter.  E.  Hunlon  (*'G>mecology  and  Alxlominal 
I  Surgery/'  Kelly  and  Noble,  Vol.  I,  p.  174)  has  eolieeted  fourteen 
I  ^ 


338  DISEASES  OF  THE  FALLOPIAN  TUBES 

cases  from  the  literature.  According  to  this  authority  the  disease 
consists  of  a  cauliflower  papillary  mass  which  originates  in  the 
mucous  lining  of  the  tube  and  distends  the  lumen  without  invading 
the  wall.  "Small  peritoneal  papillomata  may  develop,  but  metas- 
tases do  not  occur.  Like  the  ovarian  papillomata  the  tubal 
growths  often  produce  an  ascites.  If,  however,  the  abdominal 
ostium  is  closed,  there  is  no  ascites  and  the  fluid  is  either  retained 
in  the  tube  or  is  discharged  through  the  uterus  (hydrops  tubae 
profluens)."    Papilloma  of  the  tube  is  generally  unilateral. 

Embryoma. — ^There  have  been  at  least  four  authentic  eases  of 
dermoid  tumor  of  the  tube  reported  in  the  literature,  occurring 
in  patients  between  the  ages  of  twenty-five  and  forty-eight.  One 
of  the  cases  was  an  oval  tumor  the  size  of  a  hen's  egg,  which  on 
section  showed  a  tumor  mass  free  in  the  tubal  canal  and  having 
only  a  superficial  attachment  to  the  mucosa. 

Myoma  and  fibroma,  occurring  as  small  nodules  in  the  tubal  walls, 
are  not  to  be  confused  with  the  salpingitis  nodosa  of  gonorrhea 
or  with  the  nodules  occurring  in  tuberculosis  of  the  tubes.  Bland- 
Sutton  says  (*' Surgical  Diseases  of  the  Ovaries  and  Fallopian 
Tubes,"  page  286):  "I  have  satisfied  myself  that  when  there  is  a 
general  myomatous  enlargement  of  the  uterus,  the  muscle  tissue  of 
the  tubes  also  participates  in  the  change,  becoming  thick  and  hard." 

A  true  fibromyomatous  nodule  similar  in  every  respect  to  uterine 
fibromyomata  and  the  size  of  a  walnut  has  been  described  as 
occurring  in  the  tube.  Even  larger  tumors  have  been  reported. 
They  are  extremely  rare. 

Fibromyxoma. — One  case  of  fibromyxoma  of  the  tube  has  been 
n^ported  in  the  literature,  the  tumor  being  about  the  size  of  a  fist. 

Carcinoma. — Hurdon  refers  to  seventy  cases  of  primary  car- 
cinoma of  the  tube  in  the  literature.  The  disease  usually  affects 
one  tube,  though  it  may  be  bilateral.  It  occurs  most  often  in 
women  who  are  between  forty  and  sixty  years  of  age  and  chronic 
salpingitis  is  thought  to  stand  in  an  etiologic  relation  to  the  disease. 
It  originates  in  the  epithelial  covering  of  the  mucosa  and  develops 
in  the  form  of  a  papillary  tumor.  The  diseased  tube  is  converted 
into  a  large  cylindrical  pear-shaped  tumor,  which  may  reach  the 
size  of  a  child's  head,  but  is  usually  about  the  size  and  shape  of  a 
retention  tumor  of  the  tube.  The  disease  may  advance  by  direct 
extension  to  the  surrounding  structures  or  by  metastases. 


NEW  GROWTHS  339 

Sarcoma. — ^Therc  are  only  five  eases  of  this  disease  in  the  lit- 
erature, two  round-cell,  one  spindle-cell,  and  one  myxosarcoma. 
The  tumor  arises  in  the  connective  tissue  of  the  mucous  membrane 
or  tube  wall  and  presents  a  papillary  or  polypoid  character. 

Chorioepithelioma  of  the  tube,  as  a  sequence  of  tubal  gestation, 
seems  to  be  relatively  as  frequent  as  chorioepithelioma  of  the  ute- 
rus following  uterine  pregnancy.  Hurdon  notes  eleven  cases  that 
have  been  reported.  In  the  place  of  the  tube  there  is  a  large  sac 
with  thin,  friable  walls,  which  encloses  a  soft,  spongy  structure 
resembling  placenta,  and  masses  of  bloody,  fibrinous  material. 
Histologically  the  findings  are  the  same  as  in  chorioepithelioma 
of  the  uterus. 

The  diagnosis  of  neoplasms  of  the  tube  can  be  only  a  probability. 
F<)rtunat(»ly  they  an^  very  rare.  After  diagnosing  a  tumor  of  the 
tulx5  by  palpation,  the  possibility  of  its  being  a  neoplasm  should 
be  borne  in  mind. 

Tul>al  prt^gnancy  will  Ix^  considered  in  the  next  chapter  under 
Extra-uterine  Pregnancy. 


CHAPTER  XIX 

THE  DIAGNOSIS  OF  EXTRA-UTERINE  PREGNANCY 

Tubal  pregnancy,  p.  341:  Frequency,  p.  341.  Etiology,  p.  341.  Pa- 
thology, p.  343.  Uterine  decidua,  p.  344.  Fate  of  the  fetus,  p.  344.  Dis- 
eases of  the  ovum,  p.  345. 

Ovarian  pregnancy,  p.  345. 

Symptoms  and  signs  of  extra-uterine  pregnancy,  p.  346:  Pelvic  hemat- 
ocele, p.  347.     Multiple,  combined,  and  repeated  tubal  pregnancies,  p.  JJ48. 

Diagnosis,  p.  348:  Early  extra-uterine  pregnancy,  p.  348.  Late  extra- 
uterine pregnancy,  p.  350. 

Differential  diagnosis,  p.  351 :  Early  extra-uterine  pr^nancy  before 
rupture,  |).  351 .  Early  extra-uterine  jjregnancy  after  rupture,  p.  352.  Late 
extra-uterine  pregnancy,  p.  353. 

DEFINITIONS 

By  extra-uterine  pregnancy  we  understand  the  development 
of  a  f(»rtilized  ovum  at  some  point  between  the  Graafian  follicle 
in  which  it  originates  and  the  uterus. 

The  fertilized  ovum  may  develop  on  the  ovary  itself,  ovarian 
preijnaticy,  on  the  fimbria  ovarica,  one  of  the  fringes  at  the  ostium 
abdominale  of  the  Fallopian  tulx^  that  extends  from  the  ostium 
to  the  ovary,  so  called  abdominal  pregnancy,  or  in  the  tube,  tubal 
pregnajirfj. 

It  is  possible,  and  cases  have  been  rejX)rted,  of  a  fertile  ovum 
d(»veloping  in  a  tubo-ovarian  cyst,  the  fetal  sac  being  made  up 
partly  of  tubal  and  partly  of  ovarian  tissue.  Such  cases  are  s|X)ken 
of  as  Ix'ing  tubo-ovarian  pregnancies.  When  a  primary  tubal 
(ampullar)  pregnancy  has  grown  in  its  development  into  the  abdom- 
inal cavity  it  is  called  a  tubo-abdominal  pregnancy ,  and  when,  at 
the  ()|)|)()site  end  of  the  tuln*,  a  |)r(»gnancy  Ix^ginning  in  the  uterine 
end  of  the  isthmus  (interstitial  pn^gnancy)  develops  into  the  uterus 
it  is  ref(nT(Ml  to  as  tubo-uterine  prcipmncy. 

True  alxlominal  pregnancy  do(»s  not  (»xist,  the  cases  reported 
as  such  iK'Uig  those  in  which  the  growth  of  the  fertilized  ovum 

340 


TUBAL  PREGNANCY 


341 


Ix^gan  on  ovarian  or  tul>a!  >1ructure  and  the  sub?si'(|iR*nt  develop' 
rueiit  was  in  the  alxioniinal  cavity- 


TUBAL  PREGNANCY 

A  vast  nmjority  of  cxtra-utcrinr  prognancies  are  tubal,  and  of 
these  the  ampullar  form  is  |»robably  the  most  common,  though 
8c^nie  authoFH  assert  that  the  isthniial  variety  lias  tlie  |jreectlenee. 
Tlie  ifitf*rs1itial  vari<*ty  is  the  rarest.  ^ 

Frequency.— It  would  ap|M.*ar  that  (*xtra-uterirte  prej^nancy  is 
more  frequent  than  formerly,  but  whether  thii?  is  really  so  or  si>ems 


.♦W  "^110 


FlQ.  140» — Blarly    Ampullar    Extm-ut^rino    PrPKnunry^     Tubal    Abortion, 
N  at  u  ra  1  Si  zo .     ( K  elly , ) 

to  he  so  because  of  t^etter  diagnosis  and  thi^  more  cotrunon  practice 
of  oijc'nmg  the  alxlouK'ii,  is  not  plain.  Iti  bS7fi  Parry  was  al)le 
to  collect  only  500  cases  from  the  literatun*;  to-day  the  literature 
teems  with  them.  Ont*  prominent  gynecologist  in  this  country 
has  iTjKjrted  recently  having  seen  as  nmny  as  3tXJ  cases  of  extra- 
uterine pregnancy,  another  2(>i),  and  a  thinl  has  operated  on  154 
cases.  Still  another  oj>emtor  says  that  operations  for  extra-uterine 
(pregnancy  form  about  four  per  cent  of  all  his  aI>dominal  oper- 
aticjns,  and  in  my  own  experience  such  operations  have  lx*en  nearly 
five  [jer  cent  of  all  my  celiotomies. 
Etiology.— As  to  the  causation  of  tubal  pregnancy  we  are  still 


Fig,  141.— Same  Caae  aa  Iil^   i  in      rfi>-  Mnl*  ami   di.    i 
itiuvml  from  the  Tube.     (Kelly,) 

though  in  a  t-crt^in  proj>ortion  of  vtLHv^  ovon  the  most  ean*fu|l 
histoiy  of  the  patient  and  thorough  microscopic  examination 
of  the  speciiiK^n  %vill  fail  to  reveal  a  tangible  cause  for  the  condition/* 
Ajjy  woiaan  t luring  the  childlxiaring  age  may  have  extra-uterijTC 
pregnancy.  It  is  more  often  ohservcil  in  women  who  have  been 
pit!vioiisly  sti^rile  or  whrn  there  has  been  a  long  interval  sinee^ 
the  last  pregnancy. 


Pathology.— 11  api>ears  that  the  ovum 
placL*nta  is  fomied  in  the  tube  exactly  as  in  the  uterus.  The  tube 
wall  is  invaded  by  the  festal  elements,  its  structures  Ix'eome  degeii- 
eratetl  and  in  part  eunverleii  into  fibrin  so  that  they  offer  com- 
paratively httie  resistance  to  tlie  developing  fetal  cells.  Shortly 
the  latter  are  found  just  uniler  the  peritoneunu  In  a  majority 
of  ca'M^s  early  rupture  of  the  IuIk'  is  flue  to  the  erosion  of  a  large 
blood-vessel  with  consequeet  hemorrhage  and  a  giving  way  of  the 
thin  p*?ritoneum. 

Tubal  pregnancy  may  terminate  by  alwrtion  mto  the  lumen 


Fro.  142. — Fehic  Heiuatoeele. 


of  the  tube,  the  most  freiiuent  issue;  by  rupture  into  the  j>eri toned 
cavity,  bcjth  of  tlit'se  taking  place  iluring  tlm  first  ft'w  weeks  of 
pregnancy;  or  by  tlevelopment  even  to  term.  Rupture  is  more 
common  in  pn^gnancy  in  the  isthmus,  and  abortion  in  ampullar 
pregnancy. 

As  far  a8  the  results  go  it  makes  little  difference  whetlier  early 
niptuix*  takes  plai*e  through  tlie  capsular  membrane  into  the 
lumen  of  the  tube  or  through  the  wall  of  the  tub'.  There  is  a 
hemorrhage  in  either  ease.    The  ovum  with  its  membranes  is  (1) 


344  EXTRA-LTERINE  PREGNANCY 

separated  completely  from  its  bed  and  is  expelled  into  the  lumen 
of  the  tube  and  perhaj)s  through  the  ostium,  or  (2)  is  expelled 
through  the  tubal  wall  directly  into  the  peritoneal  cavity  or,  (3) 
the  separation  is  partial,  the  ovum  remains,  and  the  hemorrhage 
continues.  The  last,  incomplete  abortions,  are  the  most  frequent. 
WTien  the  ovum  and  its  envelopes  are  extruded  at  once  through 
the  ostium  abdominale  the  hemorrhage  may  cease;  when,  on  the 
other  hand,  the  separation  of  the  o\Tjm  from  the  tubal  wall  is 
only  partial,  the  ovum  may  increase  in  size  because  of  infiltration 
with  blood,  and  a  tubal  viole  is  formed.  Under  such  conditions  the 
hemorrhage  continues  as  long  as  the  mole  remains  in  the  tube 
and  the  blood  trickles  from  the  ostium  and  forms  a  pelvic  h(^ 
matocele  instead  of  free  hemorrhage  into  the  peritoneal  cavity  as 
in  the  case  of  complete  abortion  or  tubal  rupture. 

Tubal  rupture  occurs  more  frequently  in  isthmial  and  interstitial 
pregnancy  than  in  ampullar  pregnancy.  In  interstitial  pregnancy 
rupture  may  not  occur  until  as  late  as  the  fourth  month,  whereas 
in  isthmial  pregnancy  rupture  generally  occurs  within  the  first 
f(»w  weeks  of  pregnancy,  not  infrequently  before  the  patient  is 
conscious  that  she  is  pregnant. 

Rupture  occurs  near  the  placental  site  and  is  either  into  the 
pc^ritoneal  cavity  or  Ix^ween  the  folds  of  the  broad  ligament. 

Uterine  Decidua. — A  decidua,  very  similar  in  structure  to  the 
decidua  of  uterine  pregnancy,  is  fomied  in  the  uterus  coincident 
with  the  development  of  the  ovum  in  the  tube,  and  it  is  cast  off 
soon  after  the  death  of  the  fetus  either  in  small  pieces,  or,  rarely, 
as  a  complete  triangular  cast  of  the  uterine  cavity.  (Sec  Fig.  143.) 
Hemorrhage  from  the  uterus  is  apt  to  occur  when  the  decidua  comes 
away,  but  the  membrane  may  be  passed  without  the  patient's 
knowledge?.  If  portions  can  be  obtained  for  microscopic  examina- 
tion, either  from  discharges  or  by  curetting  the  uterus,  they  furnish 
a  valuable  diagnostic  sign. 

Fate  of  the  Fetus. — The  extruded  ovum  is  always  killed  and  is 
absorbed  by  the  peritoneum  unless  it  is  advanced  beyond  the 
third  month.  It  is  highly  improbable,  as  thought  formerly,  that 
the  placenta  can  be  attached  to  other  structures  in  the  abdominal 
cavity,  at  this  time.  The  facts  go  to  show  that  attachment  is 
primary  either  on  the  ovary  or  tulx*  and  that  any  other  adhesions 
are  due  to  the  later  stagers  of  the  development  of  the  fetus  and 


OVARIAN   PREGNANC\' 


345 


placenta.  If  the  rupture  is  between  {hv  UMs  of  tlie  broad  ligarnerit, 
a  mrv  hapjiening,  the  ft^tus  dies  and  a  heiiiatoma  of  the  broad 
ligament  is  formed.  Exceptionally  when  the  plaeenta  is  not 
injured  pregnancy  may  continue  in  the  broad  ligament  or  the 
broad  ligament  sac  may  rup- 
ture into  the  peritoneal  cavity 
and  a  secondary  ahdominal  preg- 
nanetj  results. 

If  the  fetus  has  developed 
beyond  the  third  month  it  may 
Ix*  jnummijietf,  consisting  of  an 
aljsorption  of  the*  fluid  |)ortion.s 
fio  that  there  is  nothing  left  but 
shriveled  skin  holding  together 
tlie  l>ones  of  the  skeh^on,  or, 
ran^ly,  it  may  form  a  lithope- 
dion,  a  mummified  fetus  in 
which  lime  salts  have  been  d<*- 
positinl  Sometimes  the  dea^l 
fetus  and  its  membranes  sup- 
purate an/1  an  aliscfss  is  formeil  p,^^  H^.-rtc^rine  DocM.m  from  a 
and  very  exceptionally  this  fetus   Case     of    Extra-l  t<jrine     Pregnane^', 

bx-omes  converte<l  into  arfi/)o-  (^^eifeU) 

cere,  a  sort,  of  amnioniacal  soap  found  o<Y*asionally  in  dead  bodies. 

Diseases  of  the  Ovum. — The  occurrence  of  tulml  molf^  ha*s  been 
referre<i  to  already,  (See  page  344/)  Hydalidiform  jnole  has  Iw^en 
found  in  the  tuiu'  and  differs  in  no  respc*ct  from  hydatidiform 
mole  occurring  in  the  uterus.  In  ttiis  situation  it  is  followed  by 
chorioepUhdionm  just  as  in  the  uterus. 

In  most  cases  of  ailvanced  tubal  pregnancy  there  is  a  diminution 
in  the  amount  of  liquor  amnii,  but  hydramnios  has  l>een  ol>served. 
There  are  two  cases  on  record  of  patients  who  had  eclampsia 
during  falsi'  labor. 


OVARIAN  PREGNATfCY 


J,  Whitridge  Williams  has  collected  from  the  literature  thirteen 
positive  cases  of  ovarian  pregnancy,  in  eleven  of  which  the  preg- 
nancy had  not  progressed  lx\vond  the  fourth  month.     In  addition 


1 


d46 


EXTRA^IITERINE  PREGNANCY 


he  classed  as  higlily  probable  or  }>ri>bal)lt'  ovarian  iiregnaney, 
twenty-two  other  ca8(*«.  In  eleven  of  these  thirty-five  cases 
pregnancy  had  progressed  to  full  term,  so  tliat  the  inference  Is 
that  the  ovary  can  aceoinino<iate  itself  more  readily  than  the 
tube  to  the  growing  fetus.     Early  rupture  is  the  rule,  however. 


Amnion. 


Parlially 
separated 
placenla. 


Ulerine 
cavity.  - 


V^ 


Cervix. 


l' 


Fig.  144. — Int<?rstilial  Pregnancy.     (Bumm), 

in  ovarian  pregnancy,  just  as  m  tubal  pregnancy.  It  is  possible 
for  the  ovura  to  be  destroyed  early  without  rupture  and  ovanun 
henmtoma  may  result.  The  implantation  of  the  ovum  on,  or  in, 
the  ovary  does  not  diflfer  from  the  emix'dding  in  the  uterus  except 
that  a  defkiite  decidua  is  wanting. 


SYMPTOMS  AND  SIGNS  OF  EXTRA-UTERINE  PREGNANCY 

There  are  no  symptoms  to  early  unrupturetl  extra-uterine  preg- 
nancy and  its  discovery  is  only  a  matter  of  chance.  Slight  pain 
in  the  ovarian  region  may  be  present.  Amenorrhea  may  be  a 
symptom,  but  cases  are  recorded  of  rupture  l>(:^fore  it  was  time 
for  another  menstrual  periml,  the  t>atient  having  no  idea  she  was 
pregnant.     Suppression  of  menstruation  Ls  not  as  frequently  a 


Ffiyraptoin  with  extra-  as  with  intra-uterine  pregnancy,  perhaps 
due  to  the  presence  of  the  utiTine  decidual  and  if  ruptiiR-  or 
abortion  take^  plaee  in  tho  tube  there  is  hemorrhage  from  the 
uteriLs.  Sometimes  the  patient  think.s  herself  pregnant  and  there 
may  be  present  signs  in  the  breasts,  bluish  diseoloration  of  tlie 
anterior  vaginal  wall  and  the  introitus,  together  with  enlargement 
of  the  Fallopian  tube  on  bimanual  pal(>ation. 

It  has  lx*en  my  experience  that  the  patient  has  skipped  one 
menstrual  period  and  has  some  sympton^s  of  pregnancy  before  the 
symptoms  of  rupture  occur.  These  are  sudden,  severe,  lancinating 
pain  in  the  groin,  bearing  down,  and  rectal  tenesmus^  followed 
at  once  by  faintness  and  sighing  respiration  with  colla|>se,  pallor, 
distention  of  the  abdomen,  a  fec»ble  rapid  pulse,  and  subnormal 
tempcratiu-e.  Patit^nts  se^ldom  die  of  this  first  hemorrhage,  but 
after  a  few  hours  there  is  another  attack  of  pain,  followed  by  greatcT 
eollaps*},  and  if  there  is  no  surgical  aid  death  may  follow% 

No  two  cases  are  alike,  one  will  bleed  rapidly  and  another  slow^ly. 
Further,  the  amount  of  collapse  does  not  seem  to  be*  in  direct 
ratio  to  the  amount  of  blocwl  which  has  escaped  into  the  peritoneal 
ea\'ity,  for  upon  operation  it  is  found  sometimes  that  when  the 
abdomen  is  full  of  lihMxl  the  symptoms  have  not  teen  severe.  In 
other  cas<\s  most  alarming  sjrmptoms  follow  the  extravasation  of 
a  small  quantity  of  blood. 

Pelvic  Hematocele. — If  the  blood  has  trickled  out  of  the  ostium 
of  the  tube^  as  in  tubal  atK*rtion,  or  if  for  any  reason  the  discharge 
of  blood  is  intennittent,  there  will  Ix;  a  sc^ries  of  attacks  of  pain, 
perhaps  a  week  or  two  apart.  In  these  cases  a  pelvic  hematocele 
is  generally  formed.  The  bloo<l  collecting  in  the  pelvis  is  partly 
coagulated  and  is  walled  oflf  by  an  organizeil  membrane  of  perito- 
nitic  exudate.  iSuch  a  collection  may  be  a  isoUtury^  or  a  diffui<e 
^lenuUocelej  the  fonner  term  k*mg  applied  to  a  smaller  collection 
of  blomi  in  the  neighlM)rlKMMi  of  the  Fallopian  tube. 

Local  examination  shows  a  lx>ggy  mass,  also  softness  of  the 
cervix,  and  pain  •on  mo\ing  it  forward  with  the  finger.  Bluish 
discoloration  <*f  the  vagina  may  be  present.  Colostrum  in  the 
breasts  is  an  unreliable  symptom*  In  some  cases  of  early  rupture 
there  is  a  uterine  discharge  of  a  brc:)w^iish  color  w^hich  may  con- 
tinue for  weeks.  This  Ls  due  to  the  disintegration  of  the  dcMi'idua 
in  the  uterine  cavity. 


1 


348  EXTRA-UTERINE  PREGNANCY 

The  pelvic  hematocele  is  generally  situated  in  the  cul-de-sac 
of  Douglas.  If  the  uterus  happens  to  be  retroverted  and  the  cul- 
de-sac  obliterated  the  blood  may  Ixj  effused  in  front  of  the  uterus 
and  in  that  case  the  hematocele  will  be  found  anteriorly.  A  fresh 
hematocele  is  flaccid  and  fluctuates;  an  old  one  is  hard  and  may 
be  of  uneven  density. 

If  rupture  does  not  result  in  death  and  there  is  no  surgical 
interference  pregnancy  may  continue  and  secondary  abdominal 
pregnancy  may  follow.  Then  the  symptoms  will  be  those  of  preg- 
nancy, with  more  pain  and  more  suffering  from  the  fetal  movements 
than  in  uterine  pregnancy.  False  labor  sets  in  at  term  with  uterine 
contractions  and  pain.  The  fetal  sac  contains  so  few  muscular 
fibres  that  it  can  not  contract  to  any  great  extent.  The  false  labor 
may  last  a  few  hours  or  a  number  of  days  and  is  followed  by  the 
death  of  the  child. 

Multiple,  combined,  and  repeated  tubal  pregnancies  are  reported 
in  the  literature.  Twin  tubal  pregnancies  occur  occasionally, 
both  embryos  being  in  the  same  tube  or  one  in  each  tube,  and 
Sanger  and  Krusen,  according  to  Whitridge  Williams,  have  reported 
cases  of  triplet  tubal  pregnancy,  all  of  the  embryos  being  of  the 
same  age.  Combined  extra-  and  intra-uterine  pregnancy  is  not 
very  rare.  Weil)el  in  1905  had  collected  119  cases  from  th(»  lit- 
erature. This  class  includes  only  the  combined  pregnancies  in 
which  the  embryos  were  of  the  same  ag(*,  and  not  the  cases  of 
uterine  pregnan(*y  occurring  in  the  presence  of  the  remains  of  an 
old  extra-uterine  pn^gnancy. 

There  have  lx?en  many  cases  on  record  of  repeated  tubal  preg- 
nancy in  the  same  woman,  and  several  cases  of  this  have  fallen 
under  my  observation. 

DIAGNOSIS  OF  EXTRA-UTERINE  PREGNANCY 

Early  Extra-utkkixk  Pregnancy 

V 

The  positive  diagnosis  of  early  tubal  pregnancy  before  rupture 
has  Ixren  made  and  has  been  proved  by  opcTation.  Such  a  diag- 
nosis is  based  on  the  symptoms  and  signs  of  (iarly  pregnancy  and 
the  presence  of  a  tender  unilateral  tumor  of  the  tube  and  slight 
enlargement  of  the  uterus,  more  c^spc^cially  if  the  woman  has  been 


DIAGNOSIS 


340 


sterile,  or  a  long  interval  has  elapsed  since  the  last  pregnancy.  A 
diagnosis  uniler  these  conditions  is  onJy  pr(jbal)Ie»  however.  Any 
patient  presenting  such  a  combination  of  f^ynif>toins  and  signs 
should  Ik?  kept  under  continued  observations  until  the  diagnosis 
is  made  phiin  or  an  operation  is  performed.  The  death  of  the  fetus, 
usually  bt^tween  the  fourth  and  the  ninth  w(*ek  of  pn^gnancy,  is 
signalized  by  the  tlischarge  of  the  uterine  decidua  and  Ijy  more  or 
less  hemorrhage  from  tlie  uterus.  At  tliis  time  the  diagnosis  is 
apt  to  be  uterine  abortion.  Always  earefull;^  examine  the  ovaries 
and  tulws  in  cases  of  aliortion  and  if  possible  get  shreds  of  extrudeil 
tissue  for  microscopic  examination.  In  exfoliative  endometritis  a 
cast  of  the  uterine  cavity  may  be  throwTi  off,  and  therefon.*  tlie 
extrusion,  in  extra-uterine  pregnancy,  of  the  tleeidua  in  one  piece, 
triangular  in  shape,  is  not  i)roof  jjositive  of  the  existence  of  this 
disease,  but  may  l>e  classed  as  presumptive  evidence.  On  the 
other  hand,  the  cast-off  dt'cidua  may  Ih.^  lost  at  an  earl}^  date, 
perhaps  without  the  jjatient^s  knowhtlge.  A  tubal  tumor  of  a 
size  corresix>nding  to  the  length  of  time  the  suppost*d  pregnancy 
has  existed,  a  slightly  enlarged  utei'us,  a  relaxed  vagina  w^ith 
l>luish  discoloration,  a  vaginal  <Jischarg(*  of  blcHMl  and  shreds  of 
tissue,  and  pain  caused  by  pullbig  tlie  cervix  forward  witli  the 
finger  in  the  vagina  make  the  diagnosis  of  tulml  pregnancy  most 
{irobable. 

The  spnfitoms  of  rupture  have  lx»t»n  eonsiilcred  under  the 
heailing  of  symi»toms,  page  347.  They  are  characteristic.  Sudden 
faintness  and  collapse,  together  with  severe  pain  in  the  region  of 
the  pelvis  in  a  woman  who  has  gone  over  her  period^  make  a  prot> 
able  iliagnosis  of  rupture  of  an  extra-uterine  pregnancy.  If  tlie 
patient  recovers  quickly  the  prolmbilitics  are  in  favur  of  its  bring 
iuYtsl  ab(jrtion.  If  there  are  recurrent  attacks  and  a  hematoc^ele 
can  be  made  out — a  boggy  mass  of  indefinite  outlin*^ — the  diagmv 
sis  of  tubal  abortion  is  untioubted.  If  the  patient  goes  from  bad  to 
worse,  and  there  are  rigiiiity  of  the  alxlomen,  increasing  alKlomi- 
nal  pain,  pallor,  sighing  respiration,  subnormal  iemiM^rature,  and 
a  threatly  pulsr,  tlie  diagnosis  is  tubal  mixture  and  tlie  aUloinen 
shoukl  Ijt;  opi^netl  at  once.  After  the  first  attack  of  cotlai)se^  and 
pain,  there  is  to  be  felt  a  mass  in  the  pelvis. 


I 


DIFFERENTL^L  DIAGNOSIS 


351 


pain  than  is  usual  in  normal  pregnancy.  The  sound  Diay  be  paast^l 
into  the  uterus  to  determine  that  it  is  empty. 

At  full  term  the  diagnr^sis  is  matle  by  a  history  of  false  later 
followed  by  a  gradual  ilecrease  in  the  size  of  the  ab<lomen.  The 
uterus  is  nearly  nonnal  in  size  and  di*sp laced  by  a  large  tumor 
either  for^^^ard  or  backward.  The  child  can  l>e  palpated  and,  if 
alive,  the  fetal  heart  j^ounds  can  be  heard.  The  diagnosi,^  at  full 
tenn  is  ea.sy  to  make,  whereas  pre\ious  to  this  time  it  i.s  thfficult. 

The  diagnosis  of  conibinefl  intra-  and  extra-uterine  pregnancy 
is  seldom  ma^lc*  previous  to  labor  or  operation.  Sometimes  in  the? 
case  of  twins  when  a  child  ha.s  Ixx^n  Ixim  from  the  uterus  and  there 
is  delayed  birth  of  a  second  child,  <\\aoiination  leads  to  the  fliagno^sis 
of  extra-uterine  fetatioTL  Also,  operation  for  ruptured  extra- 
uterine pregnan(*y  with  alxlominal  hemorrhage  may  show  the  co- 
existence of  uterine  i>regnaney. 


DIFFEREHTIAL  DIAGNOSIS  OF  EXTRA-UTERIire  PREGNANCY 


Early  Extra-Uterine  Pregnancy  before  Rupture.— Heix^  any  enlarge- 
ment of  tuLM*  or  ovary  not  greater  in  size  tlrnn  a  goose  egg  may 
be  mistaken  fur  an  extra-uterine  fetation.  The  pres<*nce  of  the 
symptoms  and  signs  of  early  (>regnancy  (see  Chapter  XXII,  page 
418)  and  the  fact  that  an  extra-uterine  sac  is  more  apt  to  be  tender, 
arc  the  only  distinguishing  features. 

Pregnancy  in  a  retro  verted  uterus  has  been  mistaken  for  extra- 
uterine i>regnancy.  A  thorough  examination,  if  necessary  with 
an  anesthetic,  ought  to  remove  all  doubt.  The  symi.jtoms  which 
accompany  retroviTsion  of  a  gravid  uterus  should  Ix*  borne  in 
mind,  viz»,  difhculty  io  micturition,  retention  of  urine,  pains  in 
the  pelvis,  and  constipation.  If  the  bladder  is  overdistended  it 
may  be  palpatetl.  Passage  of  the  catheter  establishes  the  diag- 
nosis. Uterine  fibroids  have  been  iiiistaken  for  a  gravid  tube, 
though  this  is  rare.  Fibroids  are  seldom  single  and  the  uterus 
is  apt  to  be  distorted  by  their  growth. 

Early  Extra-Uterine  Pregnancy  after  Rupture. — vSymptonis  and 
signs  of  early  pn^gnanry  with  a  paroxysm  of  severe  alxlominal 
pain,  collajise,  distention  and  rigidity  of  the  alxlomen,  thrc^ady 
pulse    and    subnormal    teni|>erature,    besides    m€*aning   ruptured 


353 


EXTRA-UTERINE  PREGNANCY 


extra-uterme  pregnancy,  may  indicate  rupture  of  an  ovarian  cyst, 
or  torsion  of  the  jx^UcIe  of  an  ovarian  cyst,  ruptur(^  of  a  j>yosxLlpiiiin 
or  even  of  an  appendiceal  abscess,  or  ruptin-e  of  a  varicose  vex, 
of  tlie  broarl  ligament.  Tin*  treatment  is  the  same  in  all  of  these 
conditions,  iinmetliate  opening  of  the  alxlomen. 

If  the  rupture  has  been  into  the  folds  of  the  broad  ligament 

tliere  will  Ix^  a  mass   of  irregular 
^-5-       -''*.  outline  at  tlie  side  of  the  uterus,  of 

^m  doughy   consistency.     It   is    to   be 

JB  /,  \  differentiattxl  from  a  pelvic  inflam- 

^^  '^^  \  ntatory  mass  by  its  lack  of  hard- 

ness, by  the  alistniee  of  the  history 
k,  I         of  infection^  and  by  the  absi*nce  o{ 

'  the  signs  of  infection  in  vagina  and 

cervix. 

In  the  event  of  s>'mptoms  of  acute 
rupture  in  uon< litions  sinmlathig 
extra-uterine  pregnancy  tlie  history 
of  the  ease  will  throw  light  on  the 
diagnosis.  In  the  case  of  an  ovarian 
tumor  the  history  will  show  the  pre- 
vious existence  of  a  tumor,  except 
in  the  case  of  a  small  one,  and  the 

T  uterus  is  not  enlarged;  in  the  case 

I  .  of  pyosalpinx  there  is  a  history  of 

•X  '  genital  infection  and  the  temjxTa- 

ture  is  apt  to  be  elevated,  also  the 
symj)toms  of  hemorrhage,^ — weak 
heart,  pallor,  sigliing  respiration, 
and  syncope, — arc  absent.  In  the 
case  of  rupture  of  an  appendiceal 
abscess^  the  same  is  true  and  in 
adilition  there  is  a  history  of  di- 
gestive disturbances,  constijiation 
alternating  with  diarrhoea,  and,  usually,  previous  attacks  of 
riglit-sided  pain.  In  cases  of  chronic  rupture,  those*  in  which  the 
symptoms  are  not  severe  and  prolonged,  uterine  abortion  is  one 
of  the  conditions  most  apt  to  h^  mistaken  for  extra-uterine  preg- 
nancy.   If  there  is  any  doubt  at  all  that  the  case  is  one  of  uterine 


Fio.  146, — Meclian  Section  fif 
the  Uterus  of  a  Case  of  Isthiniftl 
Tubal  Pregnancy  of  altout  Two 
Months,  Showing  the  Uecirlual 
Morlificiition  of  the  Endometrium, 
(Coyvelaire.) 


DIFFERENTIAL  DIAGNOSIS 

abortion,  ether  should  be  given  ami  a  thorough  bimanual  exanii- 
iiation  made.  The  uterine  hemorrhage  in  cases  of  extra-uterine 
pregnancy  is  generally  of  less  amount  than  in  cases  of  abortion 
and  the  clots  are  les?s  frequently  jiassed.  The  pain  of  rupture  is 
a  seven?,  agonizhig  sensation,  one  that  can  not  be  enduretl;  in 
the  beginning  it  is  unilateral.  The  pain  of  almrtion  is  that  of 
labor,  Ix'ginning  as  an  achhig,  drawing  pain  in  the  lumbar  region 
radiating  toward  the  hypogastriLmi, 

The  changes  in  the  size  and  consistency  of  the  uterus  are  more 
marked  in  uterine  than  in  extra-uterine  pregnancy.  In  the  case 
of  acute  pyosalpinx  or  an  exacerbation  of  a  chronic  j^yosalpinx 
there  are  no  softening  of  the  cervix  and  no  |>aiii  when  the  cervix 
is  moved  forw^ard  as  in  the  case  of  extra-uterine  pregnancy.  In 
the  ease  of  niitture  of  varicose  veins  of  the  l>road  ligament,  a  rare 
event,  there  is  nothing  to  jioint  tow^ard  a  diagnosis  nnleas  the 
patient  has  been  luider  observation  previous  to  the  rupture. 

According  to  Baumgarten  and  Poffer  (Wiener  kliniscbe  Wwhenr- 
schriftj  19f>6,  No.  12)  acetonuria  is  present  in  extra-uterine  preg- 
nancy. They  examined  the  urme  of  one  hundred  patients  and 
were  able,  by  detecting  acetonuria,  to  cUstinguish  bc*tween  extra- 
uterine pregnancy  and  other  pelvic  tumors. 

Late  Extra-uterine  Pregnancy. — If  the  walls  of  a  pregnant  uterus 
are  abnormally  thin,  and  the  walls  of  the  mother's  abdomen  are 
also  thin,  the  fetus  may  tie  so  |>laiidy  felt  that  a  uterine  may  Ijc 
mistaken  for  an  extra-uterine  fetation.  Careful  bimanual  pal- 
pation will  determine  that  tlie  fetus  is  in  the  uterus.  So,  also,  a 
sacculated  pregnant  uterus  may  simulate  extraruterine  pn^gnancy, 
m  well  as  ijregnancy  in  a  bicorned  uterus.  In  the  latter  case  an 
other  examination  may  serve  to  differentiate. 

A  late  extra-uterine  pregnancy  with  an  excess  of  hydramnios 
may  simulate  ovariati  cyst.  If  the  fetus  can  be  outlined  by  jial- 
pation,  or  the  fetal  heart  heard,  the  diagnosis  is  easy. 

The  consideration  of  pregnancy  in  abnornuil  uteri,  such  as 
bicorned  antl  rutlimentary,  will  be  found  in  the  chapter  un  preg- 
nancy, page  432, 


23 


C'HAITER  XX 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  VAGINA 

Anatomy,  p.  354:    Vaginal  discharge,  p.  S3o.     Age  changes,  35G. 

Malformations  of  the  vagina,  p.  356 :  Congenital  malformations,  p.  356. 
Acffuired  stenosis  and  atresia  of  the  vagina,  p.  359. 

Inflammations,  p.  361 :  Acute  vaginitis,  p.  36^.  Chronic  vaginitis,  p. 
363.  Condylomatous  vaginitis,  p.  363.  Emphysematous  vaginitis,  p.  364. 
Mycotic  vaginitis,  p.  364.  Ulcerative  vaginitis,  p.  3^.  Senile  vaginitis,  p. 
365.    Tuberculous  vaginitis,  p.  365.    Syphilitic  vaginitis,  p.  365. 

Displacements  of  the  vagina,  p.  366:  Cystocele,  p.  366.  Rectocele,  p. 
369.    Hernia  or  enterocele,  p.  371. 

Injuries  of  the  vagina,  p.  371 :  Lacerations  of  the  perineum  and  pelvic 
floor,  p.  371.    Other  injuries,  p.  372. 

Foreign  bodies  in  the  vagina,  p.  377.    Gas  in  the  vagina,  p.  378. 

Vaginismus,  p.  378. 

New  growths  of  the  vagina,  p.  379. 

Fistuhe  of  the  vagina,  p.  384. 

ANATOMY 

The  vagina  is  a  slit  in  the  [)elvic  floor  extending  from  the  hymen 
to  the  cervix  uteri  and  lying  between  the  bladder  in  front  and 
the  rectum  behind.  It  is  nearly  parallel  to  the  plane  of  the  brim 
of  the  true  pelvis,  and,  with  the  patient  in  the  upright  posture, 
makes  an  angle  with  the  horizon  of  about  6(F.  When  seen  in  a 
median  longitudinal  section  the  slit  of  the  vagina  shows  an  S  curve, 
the  height  of  the  first  anterior  protuberance  of  the  S  being  at  the 
summit  of  the  perineal  body.  (See  Figs.  6,  p.  44  and  85,  p.  219). 
In  horizontal  section  in  its  middle  course  it  is  seen  as  an  H-shaped 
op(»ning.  (S(»e  Fig.  151,  p.  374.)  Like  the  cavity  of  the  uterus  it  is 
funnel-shap(»d,  l)eing  larger  alx)ve  and  smaller  below,  and  it  lias  two 
walls,  an  anterior  and  a  posterior,  which  are  in  apposition  uidess 
the  vagina  is  distended. 

The  anterior  wall  ext(*n(ls  from  the  hymen  below,  to  the  cervix 
abov(^  th(i  anterior  fornix  being  th(»  space  formed  between  the  intra- 
vaginal  portion  of  the  cervix  and  the  upixT  portion  of  the  anterior 

354 


ANATOMY 


335 


wall.  The  length  of  the  anterior  wall  i^  from  two  to  two  mid  a  half 
inches  (5  to  6  centimeters).  In  its  lower  ix»rtion  it  is  clot^*ly 
united  with  the  urethra,  but  higher  up  is  surrouiidetl  by  loose 
areolar  ti^ssue. 

The  posterior  wall  extends  from  the  hymen  to  the  cervix  uteri. 
It  is  three  inches  (7.5  eentimeteiT^)  long  or  nt*arly  an  inch  longer 
than  the  anterior  wall.  The  space  between  the  vaginal  i>ortion 
of  the  cervix  and  the  upper  part  of  the  pOi>terior  wall  is  calletl 
the  posterior  fornix.    It  is  deepcT  than  the  antt»rior  fornix. 

The  mucous  membrane  of  the  Viigina  is  arrang<*(^l  in  transverse 
folds  or  rugie.  In  the  lower  i>art.  of  the  centre  of  each  wall  is  a 
shigle  or  double  longitudinal  Uiickenlng  about  st^ven-eighths  inch 
long,  known  as  the  column  of  the  vmjina.  The  anterior  column  is 
tlie  larger. 

The  vagina  is  ma<le  up  of  three  coats,  the  mucous  membrane. 
the  muscular  coat,  and  the  erectile  tissue  lying  between  the  two. 
The  arrangement  of  the  mucous  membrane  in  fohls  has  lx*eu 
iieserilR^l.  The  epithelium  eovt'ring  the  surface  of  the  nmcous  mem- 
brane is  of  the  scjuamous  variety.  There  are  no  functioning  glaruls, 
although  the  presence  of  glantl  tissue  in  the  mucous  membrane 
has  Ix'cn  proveil  by  von  Heiff  and  It.  ih^ver.  Tlie  muscular  coat 
consists  of  two  layei-s,  an  external  longituilinal,  tlie  stronger,  and 
an  internal,  weaker,  circular  layer.  The  loose  connt»etive  tissue 
uniting  the  mucous  meoibrane  witli  the  muscular  coat  contains  a 
plexus  of  veins  wliich  are  arranged  similarly  to  the  veins  in  other 
ert*ctile  tissues.  Because  of  its  opening  near  the  anus  and  the 
urethra,  and  its  being  invaded  by  the  jjenis,  the  vagina  is  esiM'cially 
suljject  to  inflection  from  outside.  Bacteria  may  Ur  l>rought  to  it 
from  tlie  uterus  and  trauma  may  comt^  from  childlxaring. 

Vaginal  Discharge.^ — Although  under  normal  conditions  po.sses- 
sing  no  functioning  glands  and  therefore  no  stTreticjn  proper,  the 
surface  of  tbe  vagina  is  covered  by  east  off  e|»tthelial  cells  ami 
also  bacteria  with  moisture  having  an  acid  reaction.  This  has  a 
wliite  creamy  color  anil  is  not  enough  in  amount  to  attract  the 
woman's  attention.  The  aciflity  of  the  fluid  may  te  due  to  the 
lactic  acid  bacterium  of  Doderlein,  though  authorities  are  not 
agjeeil  on  this  [joint.  Be  tliat  as  it  may,  pathogenic  bacteria,  unless 
es|x^ially  virultmt*  do  not  live  long  in  a  healtliy  vagina,  not  finding 
a  good  eultuj'e  medium  or  Ixiug  killed   by  the  microorganisms 


M 


356  DISEASES  OF  THE  VAGINA 

already  there.  Under  pathological  conditions  an  excess  of  alkaline 
secretion  from  a  cervical  catarrh  may  neutralize  the  acidity  of  the 
vagina  and  render  it  alkaline,  thus  furnishing  an  opportunity  for 
the  growth  of  disease-producing  germs. 

Age  Changes. — In  the  child  the  vagina  is  narrow  and  there  are 
many  rugae.  Its  walls  are  in  close  apposition.  In  the  adult 
nulliparous  married  woman  the  vagina  is  more  capacious,  th(» 
widening  being  more  in  the  upper  than  in  the  lower  portion. 
After  childbearing  the  vagina  loses  some  of  its  folds,  is  larger,  and 
may  show  alterations  in  shape  because  of  its  attachments  being 
stripped  from  the  cervix,  or  from  laceration  of  the  perineum. 

With  the  onset  of  the  menoi)ause  atrophic  changes  begin.  The 
mucous  membrane  loses  its  ruga)  and  becomes  smooth,  and  the 
vagina  becomes  contracted.  In  its  upper  portion  the  fomices  arc 
obliterated  because  of  atrophy  of  the  cervix  and  shrinking  of  the 
vaginal  walls. 

MALFORMATIONS  OF  THE  VAGINA 

Malformations  of  the  vagina  are  congenital  or  acquired.  As  the 
vagina  as  well  as  the  uterus  is  derived  from  the  coalescence  of 
Miiller's  ducts  it  partakes  of  the  congenital  malformations  of  the 
uterus. 

Congenital  Malformations. — ^These  are:  absence  of  the  vagina, 
atresia  of  the  vagina,  septate  vagina,  double  vagina,  and  per- 
sistence of  a  Miiller^s  duct,  also  the  persistence  of  Gartner's  duct. 

Absence  of  Oie  Vagina. — ^This  is  not  a  very  uncommon  malfor- 
mation, instances  of  it  appearing  constantly  in  the  periodical 
literature.  It  is  associated  with  a  greater  or  less  degree  of  lack 
of  d(*velopment  of  the  uterus,  the  uterus  being  represented  gen- 
erally by  a  small  knob  of  tissue.  The  ovaries  and  tubes  may  or 
may  not  be  prest^nt.  If  the  ovaries  are  present  the  patient,  other- 
wise perfectly  formed  as  regards  figure,  external  genitals,  breasts, 
and  hair,  suffcTs  from  painful  menstrual  moUmina,  and  an  oper- 
ation for  the  removal  of  the  ovaries  may  be  necessary.  The  anomaly 
occurs  without  assignable^  cause  in  well-nourished  women  in  other 
respects  fully  developed. 

The  diagnosis  is  established  by  noting  the  absence  of  the  introitus 
vagina)  and  by  the    bimanual    recto-abdominal  touch  practised 


MALFORMATIONS  OF  TIIC  VAHINA 


357 


with  the 


patient  uiuler  tlit-  influence  of  an  anesthelic.  Something 
is  learned  also  by  palpation  through  tlie  reetuni  with  a  sound 
j)laced  in  the  urethra  and  bladder.  As  a  rule  no  vestige  of  the 
vagina  can  h(y  found  in  the.se  eases.  The  entire  absence  of  the 
ovaries  can  not  Ix*  detennined  surely  without  au  abdominal  section, 
but  failure  to  find  them  in  a  case  w^here  all  the  conditions  for 
examination  are  favorable,  i.e.,  lax  and  thin  alMlominal  walls, 
together  with  the  absence  of  menstrual  molimitui,  makes  the 
diagnosis  reasonably  certain* 

Atresia  of  the  Vagina  {Congenital), — Vaginal  atresia  is  due  to 
the  fact  that  the  Miiller*s  duets  fail  to  coalesce  properly  throughout 
their  entire  course,  and  the  lower  end  of  the  vagina  may  fail  to 
reach  the  hymen.  As  a  rule  there  is  some  portion  of  the  unocclude*J 
vagina  just  under  the  cervix.  In  cases  of  congenital  atresia  of  the 
vagina  the  vagina  has  been  found  dilatal  with  secretion  so  that  it 
bulgnl  Ix'yond  the  vulva,  and  lias  Ix^^n  known  to  cause  rett^ntion  of 
urine  in  the  new-bom  because  of  pressure  on  tlie  lu-ethra. 

Occlusion  of  the  vagina  is  to  be  differentiated  from  imperforate 
hymen,  the  latter,  Ix'ing  developed  from  the  margins  of  the  urogeni- 
tal sinus,  is  not  a  complete  obstructive  membrane.  It  is  likely 
that  when  the  hymen  is  closeii  the  closure  is  the  result  of  ailhesive 
inflammation.  The  hjonen  can  generally  be  recognized  as  a 
separate  structm'e  bc*low  the  introitus  vaginie. 

■  Any  defect  of  the  vagina  that  causes  retention  of  thi*  uterine 

■  secretions  should  Ix^  diagnoseil  at  birtli  or  soon  after. 

^^^  In  ^he  case  of  doubk'  uterus  and  vagina  one  vaguia  may  apjK^ar 
^^^  a  blind  sac  rmuiing  beside  the  well-formed  vagina.    It  is  thought 

■  now  that  most  cases  of  atresia  of  the  vagina  owe  their  origin  to 
I  inflammatory  proceas€\^,  pcThaps  diu-ing  intra-uterine  life,  although 
I  there  are  cases,  mahily  those  associated  with  uterine  abnormalities^ 
I      that  are  due  to  failure  of  <levelopment  pure  and  simple. 

I  The  (Hagnoeis  Ls  generally  made  by  chance  or  by  the  occurrence 

■  of  hematocolpos  or  liematometra  due  to  retaintnl  secretions  in 
the  vagina  or  uterus, 

■  Septate  vagina  and  dmihle  vagina  occur  when  the  septum  between 
the  Miillerian  duct^  is  partially  or  not  at  all  absorbed.  The  partial 
form  is  more  oftf*n  obserA^ed.  alth<:mgli  all  forms  are  rare.  The 
septum  may  be  placed  diagonally  s*)  that  it  has  the  appearance 

I      of  a  transverse  septum,  thus  partially  occluding  one  side  of  the 


wall  of  a  w<4lHjcvf loped  vagina  and  is  connected  alcove  with  a 
nidinif^ntary  8up<vriuii«crar)^  uterus  while  having  no  opening 
Wow,  it  may  become  dilated  by  retahied  secretions  and  appear 
as  a  cyst.    Freund  antl  otht^r^  have  reiKJiled  sneh  eases. 


k 


MALFORMATIONS  OF  TIIE   VAGINA 


359 


I 


Several  cases  of  tlouble  vagina  have  IxTn  report tH I,  ii<>tal)ly  t>ue 
of  double  vagina  aiitl  ilouble  uterus  ri*ix)rtecl  by  II.  A.  Kelly 
("Operative  Gynecology,"  2nd  edition,  page  210,)     (See  Fig.147.) 

Gfirlner^s  dud^  which  in  the  emliryo  extfiids  as  a  small  canal 
tlLrough  the  sidi*  of  the  uterus  or  the  l>road  tigaitient^  tiie  rervix, 
anil  the  lateral  or  anterior  wall  of  the  vagina  nearly  to  the  introitus 
vaginie,  may  persist  in  the  wall  of  the  adult  vagina.  This  may, 
rarely^  give  rise  to  cysts  or  even  to  an  abscc'ss. 

Rt^tention  of  eeei-etions  due  to  atn;%sia  of  the  vagina,  heinato 
coli>os,  will  be  considered  under  actjuired  stenosis  and  atresia  in 
the  section  on  inllannnations. 

The  diagnosis  of  malformations  is  made  by  insjXH^tion  and  by 
<ligital  examination.  A  small  s|>cculum  is  necessary  and  sometimes 
a  K(*lly  cystoscope  serves  well  for  a  view  of  an  undeveloped 
va^ria.  Bimanual  reetoalxlotninal  touch  will  deterniiuc  the 
condition  of  the  uterus  and  ovaries. 

Acquired  Stenosis  and  Atresia  of  the  Vagina. — Stenosis  of  the 
vagina  is  a  constriction  or  narrowing  of  the  canal,  %vhile  atresia  is  a 
complete  closure  or  obliteration  of  it, 

J.  Veit  (**nandbych  der  Gynakolo^e,"  Bd.  Ill,  l9tlS)  thinks 
that  most  of  the  forms  of  vaginal  atresia  that  cause  retention  of 
secretions  a»s  seen  in  the  adult  (hematocolpos)  are  to  be  classed 
as  acquircil,  and  assigns  atlhesive  inflammation  in  the  first  ytvii's 
of  life  as  a  cause.  This  inflammation  is  not  as  a  rule  severe  mu\ 
has  no  symptoms  often.  We  knfjw  of  tlu*  frequency  of  gonorrheal 
\iilvo-vaginitis  in  little  girls,  and  also  that  inflanmiatory  affections 
of  the  vagina  are  found  hi  septicemia^  scarlet  fever,  ami  diphtheria. 
Also,  bacteria  fincl  ready  entrance  to  the  vagina  in  typhoid  fever, 
dysentery,  ami  similar  aflfections.  Taken  in  connection  with  the 
frer|uency  with  which  traces  of  infiamniatory  action — for  exairi|>lt% 
mlhesions  of  the  prepuce  to  the  clitoris — are  found  in  adults  ufMin 
cart'ful  search,  there  s<*ems  to  be  ample  ground  for  the  th<H)ry  that 
this  sort^  of  atresia  originat(»s  in  adhesive  inflammation. 

In  atlults  the  cause  r>f  cicatricial  stenosis  is  intianmiatory  action 
involving  the  submucous  antl  nmscular  layers,  due  to  injuries 
following  childbirth,  to  caustic  apiilications  to  the  vagina,  to 
improj^jti'ly  |>erformeil  operations  on  the  vagina,  to  foirign  bodies 
left  in  the  vagina,  such  as  neglected  pessaries,  and  to  vaginitis 
phlegmonosa  disscccans.    As  a  result  there  are  found  in  the  vagina 


360  DISEASES  OF  THE  VAGINA 

cresccntic  folds,  ring-like  narrowings,  transverse  septa  with  minute 
openings,  all  being  forms  of  stenosis,  or  there  is  a  general  shutting 
up  of  the  entire  canal,  atresia.  This  atresia  may  be  caused  by  a 
thin  membrane,  by  a  broad  cicatrix  several  centimeters  thick, 
or  by  the  entire  destruction  of  the  vagina. 

Atresia  or  stenosis  results  in  difficulty  in  coitus  and  in  labor. 
In  the  congenital  form  of  atresia  of  the  genital  organs  there  is 
apt  to  be  diminished  desire  for  sexual  intercourse,  especially  if 
the  ovaries  are  undevelopd.  Another  result  of  atresia  is  hemato- 
colpoSy  or  accumulation  of  menstrual  blood  and  uterine  secretions 
in  the  vagina.  These  cases  are  generally  first  seen  in  girls  who 
have  passed  the  age  of  puberty  without  the  appearance  of  the 
menstrual  flow.  They  may  experience  pain  in  the  abdomen. 
Examination  shows  a  tumor  behind  the  pubes  that  increases  in 
size  at  each  menstrual  period  and  diminishes  in  the  interval. 
On  inspection  of  the  vulva  there  is  to  be  noted  a  bulging  outward 
in  the  region  of  the  introitus  vaginae  of  an  elastic  tumor.  The 
hymen  is  to  be  distinguished  as  a  separate  membrane.  If  the 
septum  of  the  vagina  is  thin  the  dark  color  of  the  retained  blood 
may  manifest  itself  through  the  membrane.  The  bimanual  recto- 
abdominal  touch  determines  the  presence  of  a  fluctuating  tumor 
in  the  situation  of  the  vagina. 

If  the  accumulation  of  blood  and  uterine  secretions  has  dilated 
the  uterus,  liematoynetra,  it  may  be  possible,  with  the  aid  of  an 
anesthetic,  to  palpate  the  enlarged  uterus.  Dilatation  of  the 
Fallopian  tubes  from  the  same  cause,  hematosalpinx,  sometimes 
results.  In  the  latter  event  there  may  be  an  escape  of  fluid  through 
the  ostium  abdominale  of  the  tube  into  the  peritoneal  cavity  with 
resulting  peritonitis  and  symptoms  of  a  severe  grade.  The  danger 
of  causing  such  extrusion  of  fluid  should  be  borne  in  mind  in  making 
the  bimanual  touch  and  the  amoimt  of  force  used  should  be  carefully 
limited.     (Sch)  Chapter  XXI,  p.  398). 

Diagnosis, — The  diagnosis  of  stenosis  and  atresia  of  the  vagina 
offers  few  difficulties.  The  examining  finger  detects  folds  and 
ridges  and  partial  narrowings,  also  double  vagina,  if  present.  A 
small  speculum  is  generally  indicated,  for  with  it  the  physician 
gets  a  better  view  of  an  abnormally  narrowed  vagina.  An  open 
canal  with  an  elastic  tumor  by  its  side  makes  probable  a  dilated 
rudimentary  vagina.    Cyst  of  the  vagina  must  be  excluded,  how- 


INFLAMMATIONS  OF  THE   VAGINA 


361 


ever,  and  this  can  \ye  clone  by  determining  the  ooriDal  state  of 
the  uterus,  tubes,  and  ovaries,  as  rudimentary  vagina  is  seldom 
found  with  the  other  uterine  organs  perfectly  normal.  In  all 
cases  it  is  important  to  investigate  the  uterus  and  tuljes. 

Differential  Diagnoms^-^Aciimwil  stenosis  and  atresia  must  be 
different iatetl  from  the  congenital  malformations,  from  vuhatis 
with  atresia,  and  from  vaginismus.  The  congenital  malforma- 
tions are  of  relatively  rare  occurrence  and  are  associated  with 
other  defects  of  development  in  uterus,  tubes,  or  ovaries,  their 
salient  characteristics  having  been  referred  to.  In  adhesive  vnil- 
vitis  there  are  apt  to  l>e  traces  of  inflamniatory  action  (adhesions) 
about  the  clitoris  and  n>Tnpha%  as  well  ns  at  the  introitus  vagina. 
There  may  be  a  history  of  gonorrhea,  in  this  case  look  for  cicatri- 
zation or  redness  in  the  neightorhood  of  the  \iilvO'Vaginal  glands; 
or  there  may  Ixj  a  history  of  diabetes.  Vaginismus  is  characterize^i 
by  painful  and  spasmodic  contractions  of  the  muscles  of  the  pelvic 
floor,  especially  those  about  the  lower  vagina.  In  cases  of  doubt 
the  administration  of  an  anesthetic  will  relieve  all  spasm. 


IFFLAMMATIONS  OF  THE  VAGINA 

{Vaginilis  nr  Cdpilis) 

Infection  of  the  vagina  depends  on  the  number  and  vitahty 

of  the  pathogenic  bacteria  that  have  found  their  way  into  it;  also 
on  the  state  of  health  of  the  epithelium  of  the  mucosa  of  the  vagina. 
Any  direct  injury  of  the  epithelium,  or  change  in  its  character  due 
to  a  uterine  catarrh  favors  the  development  of  infective  organisms, 
and  their  entrance  into  the  tissues.  Just  what  Imcteria  are  present 
as  causative  agents  in  any  given  case  it  is  not  always  easy  to 
determine;  those  that  are  most  often  found  are  the  streptococcus, 
the  staphylocfjceus,  the  coUm  haeilliis,  the  tubercle  bacillus,  the 
gonococcus,  and  a  gas-producing  bacillus. 

Vaipnitis  is  relatively  more  common  in  children  than  in  atlults, 
\  probably  because  of  the  softer  epithelium  in  childhood.    In  children 
\idvo- vaginitis  of  gonorrheal  origin  is  not  uncommon,  and  vagi- 
nitis is  a  fre<iuent  concomitant  of    the  acute  infectious  diseases. 
In  adults  vaginitis  is  a  rare  disease* 
Etiology* — The   following   may   be   mentioned   as   predisposing 


362  DISEASES  OF  THE  VAGINA 

and  exciting  causes  of  vaginitis:  Retained  discharges  from  an 
insufficient  opening  in  the  hymen;  irritation  from  excessive 
venery  or  masturbation ;  congestion  from  pregnancy  or  abdominal 
tumor,  or  organic  disease  of  the  heart,  liver,  or  kichieys;  gaping 
of  the  vulvo- vaginal  orifice;  douches  of  irritating  substances, 
such  as  strong  corrosive  sublimate;  foreign  bodies,  such  as  pes- 
saries and  tampons;  oxyuris  vermicularis;  injuries  received  at 
labor  and  abortion,  and  recto-  and  vesico- vaginal  fistula). 

ACITTE  VAGixms 

Pathology. — In  the  mild  cases  it  is  characterized  by  a  reddened, 
swollen,  granular  mucosa  which  is  bathed  in  an  abundant  thin 
purulent  discharge.  The  entire  vagina  is  usually  involvc^l.  In 
the  severe  cases,  swelling  and  hyfxiremia  increase  and  excoriations 
and  even  necrosis  may  occur.  In  puerperal  conditions  and  in  the 
acute  infectious  diseases  the  mucosa  may  be  covered  with  a  whitish- 
gray  or  greenish  deposit  or  by  a  false  membrane  made  up  of  the 
necrosed  upper  portion  of  the  mucosa — pseiida-diphtheritic  vaginitis. 
Cases  of  true  diphtheritic  mflammatiiyriy  due  to  the  Klebs-Locffler 
bacillus,  have  Ix^en  described,  though  they  are  rare. 

In  certain  extremely  severe  cases  the  inflammatory  process 
extends  to  the  tissues  about  the  vagina  and  there  is  a  paravaginitis. 
This  is  the  case  in  an  erys^i pehitous  vaginitis  similar  to  the  erj'sipelas 
of  the  skin,  a  rare  disease*,  and  in  paravaginitis  pldegmonosa  dis- 
siccanSy  which  sometimes  accompanies  typhoid  fever.  In  the 
phlegmonous  variety  the  whok*  or  the  greater  part  of  the  tube  of 
the  vagina  is  cast  off  as  a  slough  with  subseciuent  stenosis. 

Symptoms. — Burning  pain  refernnl  to  the  vulva,  a  profuse 
leucorrheal  discharge^  gen(*rally  purulent  in  character  and  irritating 
to  th(^  vulva,  smarting  on  urination  if  the  vulva  is  involved  and 
also  if  urethritis  is  pn^senit,  a.s  in  the  gonorrheal  form,  a  sense  of 
fulln(*ss  in  thc^  pelvis,  and  backache,  are  the  usual  symptoms. 
Vulvitis  go(\^  with  vaginitis  in  many  cases,  especially  in  children. 
The  constitutional  symptoms  are  not  marked,  the  temperature 
seldom  going  above  101°  F.,  except  in  the  streptococcic,  diphthe- 
ritic, and  paravaginitic  forms. 

Diagnosis. — The  pati(^nt  is  plac(Ml  in  the  Sims  position  and  the 
labia  are  separated.    The  charactcT  and  amount  of  discharge  are 


INFLAMMATIONS  OF  THE   VAGINA 


3a3 


notrd  and  a  fmgvr  |jla(*rd  in  thv  vagina  finds  that  it  is  hoi.  In 
the  gonorrheal  variety,  whieh  18  relatively  rare  aiitl  is  sc*eonilary  to 
infeetioD  of  Bartholin's  glands,  the  urethra,  and  cervieal  canal, 
the  diseharis^e  is  generally  of  a  greenish-yelk^w  color,  Tlie  smallest 
Sims  speeuhun  that  will  s«Tve  is  used  because  the  vagina  is  very 
sensitive.  The  mucous  menil)ra]ie  shows  sr^rne  of  the  many  char- 
aettTisties  descril^ed  under  the  iiathology  of  acute  vaginitis.  If 
the  vaginal  disciiarge  originates  from  the  uterus  or  an  al>seess 
diseliargirig  into  the  vagina  instead  of  from  the  vagina  itself,  the 
siK-eulum  examination  will  settle  tliis  i>oint. 


Chronic  VAcmiTis 

Patiiology.— Chronie  vaginitis  may  succeed  aeutn  vaginitis,  or, 
more  often,  may  iye  of  a  chronic  type  from  the  beginning.  It  is 
apt  to  result  from  the  irritation  from  |jessaries  or  tamtKms^  *.)r 
other  foreign  lx)dies.  In  the  gonorrheal  form  it  is  usually  secondary 
to  gont^rrheal  infection  of  the  uterus,  Bartholin's  glamls,  or  the 
canal  of  the  eervix  uteri. 

Tlie  disease  is  generally  confined  to  certain  [Kirtions  of  the 
vagina  rather  than  to  the*  entire  surface,  as  it  is  in  the  aeute  fornu 
Tlie  affected  portions  are  redd(*ne<l^  often  mottled  with  slight 
c»(*ehyinos<*s,  or  tliey  are  l>ro wn  in  color  from  old  dt^iMisits  of  t)lood 
pigment.  Tlie  surface  is  granular,  or  glazni  and  smooth  anil  frt*e 
from  nigir.  Microscopically  it  is  se^^n  that  the  surface  e[>it helium  is 
somewlmt  thituier  than  normal,  whereas  the  submucous  tissue  is 
tliick,  dense,  and  infiltrated  with  small  round  cells;  sometimes 
blood  pigment  shows  in  deposits  in  places.  In  granular  vaginitis 
the  granulations  on  the  surface  are  crescent-shapiHl,  small  in  size, 
and  pretty  generally  scatteriMl  over  the  surface  of  tlie  vagina. 
Certain  special  varieties  of  chronic  endometritis  are  observed. 

Gonorrheal  vafjinitis  should  Im*  mentioned  as  a  variety,  although 
it  has  few^  eharactc^ristics  that  <hstinguish  it  fn*ni  sim[jle  vaginitis. 
It  is  generally  secondary  to  gonococcus  infwtion  els4*where  and 
the  dist^-harge  is  apt  to  be  of  a  greenish  color, 

Cmidylmnatous  Va/finilu. — Condylomata  similar  to  thase  found 
about  the  \ailva,  but  set  not  so  close  together,  are  to  Ix"  found 
sometimes  m  vaginjr  that  have  U'vn  subject  to  long-continuiHl 
irritations,  as  from  gonorrheal  endocervicitis.      The  condylomata 


364  DISEASES  OF  THE  VAGINA 

may  be  scattered  over  a  large  or  a  small  area  in  the  vagina.  They 
show  under  the  microscope  hyperplasia  of  the  papillae  accompanied 
by  secondary  epithelial  proliferation. 

Emphysematous  Vaginitis. — ^This  variety  occm^  most  often 
dming  pregnancy  and  occasionally  dm-ing  the  puerperium,  and 
is  characterized  by  the  presence  in  the  vaginal  walls  of  small  cysts, 
generally  not  much  larger  than  a  pea,  and  containing  gas.  They 
may  appear  to  be  bluish  in  color  due  to  the  thinness  of  their  walls. 
They  are  due  to  a  gas-producing  bacillus  the  exact  nature  of  which 
has  not  been  determined,  and  are  developed  in  the  connective- 
tissue  spaces.  Sometimes  the  cysts  are  as  large  as  a  filbert.  On 
pressure  with  the  finger  the  cyst  disappears,  and  on  opening  it 
with  a  knife  gas  escapes. 

Mycotic  Vaginitis, — ^This  is  a  form  of  vaginitis  in  which  there 
is  a  growth  of  a  fungus  in  the  vagina,  the  Oidium  albicans.  The 
walls  of  the  vagina  are  covered  with  large  numbers  of  grayish- 
brown,  slightly  elevated  masses  which  are  easily  detachable. 
Beneath  them  the  mucosa  is  swollen  and  eroded.  Under  the 
microscope  the  masses  are  seen  to  be  made  up  of  epithelial  cells 
and  the  spores  and  mycelium  of  Oidium  albicans.  It  has  been 
thought  that  the  dark  color  is  due  to  blood-coloring  matter. 

Ulcerative  Vaginitis. — ^Ulcerative  vaginitis  is  a  term  used  to 
distinguish  the  form  of  the  disease  in  which  the  mucosa  has  been 
destroyed  by  ulceration,  as  in  the  case  of  an  ill-fitting  pessary. 
Following  the  true  form  of  ulceration  in  which  the  submucous  tissue 
is  involved  a  cicatrix  results. 

An  interesting  case  of  ulcerative  vaginitis  in  a  case  of  bacillary 
dysentery  has  been  reported  by  M.  M.  Canavan  {Boston  Med.  and 
Surg.  Jour.,  Nov.  11,  1909,  page  705).  In  this  case  a  woman  fifty- 
one  years  old,  an  inmate  of  the  Danvers  State  Hospital  for  the 
Insane  for  four  years,  was  affected  by  bacillary  dysentery  during  an 
epidemic  of  the  disease  in  1908.  She  died,  just  after  a  vaguial 
hemorrhage,  on  the  fourteenth  day  of  her  illness.  At  the  autopsy 
the  following  condition  was  found,  to  explain  the  hemorrhage  and 
a  bloody  vaginal  discharge*  which  had  fx)(^n  noted  during  the  last 
six  days  of  her  illneas.  The  surface  of  the  vagina  was  dull  brown- 
ish-gray in  color  and  was  covered  with  a  tenacious  pigmented  exu- 
date and  there  were  clusters  of  deep-notched  winding  ulcers  at  the 
fomices  of  the  vagina. 


INFLAMMATIONS   OF   THE   VAGINA 


365 


Senile  Vaginitis. — In  senile  vaginitis,  a  form  of  vaginitis  peculiar 
to  women  who  have  passed  the  menopause,  the  mucous  membraiK? 
is  atrophic  and  thorefore  jjoorly  nourishes L  The  irritation  of  the 
vjigina  from  a  uterine  dij^charge  is  apt  to  proceeii  to  ihv  stage  of 
ulceration,  generally  many  tsmall  scattered  ulcers  Ijcing  present. 
These  enlarge,  coalesce,  cause  hemorrhage  by  the  erosion  of  small 
vessels,  and  form  scar  tissue.  There  njay  be  adhesions  between 
the  walk  of  the  vagina.  The  disease  is  a  commun  one  in  women 
over  sixty  years  of  age. 

Tubercuhns  Vaffinilis, — This  variety  is  practically  always  second- 
ary to  tulx*rculosis  elsewhere,  although  a  problematical  case  of 
primary  tuberculosis  of  the  vagina  has  been  reported  by  Carl 
Friedlander  and  Olshausen.  The  disease,  not  a  common  one, 
occurs  in  tlu*  form  of  one  or  more  ulcerations^  generally  situated 
in  the  neighborhood  of  tlie  cer\ix.  The  ulcei*s  are  flat,  circum- 
scribed, with  infiltrated  hyperemic  margins,  the  Ijasc  covered 
with  yellowish-gray  material  or  studderl  with  tulxTcles,  I  list*  h 
logically  the  tlour  of  the  ulcer  consists  of  granular,  caseous  material, 
btmeath  which  the  tissue  is  infiltraieil  witli  typical  miliary  tulxT- 
cles  or  diffuse  tuberculous  tissue.  TIic  tUagnosis  is  made  by  the 
microsco|x\ 

Si/philitic  vaginitis  needs  only  to  be  mentioned.  Chancres, 
ulcers,  or  gununata  may  be  found  in  the  vagina.  They  are  rare 
and  are  fliagnosi^Ll  by  the  chaiiicteristic  lesions  of  the  disease  in 
otlier  parts  of  the  \yody,  by  thi^  historj^  of  syphilis,  and  by  the  de- 
tection of  the  spirocliaeta  pallida  in  the  discharge. 

Symptoms.— The  symptoms  of  chronic  vaginitis  are  vagina! 
discharge,  generally  purulent  in  character,  a  sensation  of  fuUness 
in  the  pelvis,  perhaps  itching  of  the  vulva  with  smarting  on  urina- 
tion if  the  \^lva  also  is  affected  The  general  health  may  suffer 
I  as  a  result  of  the  irritation  and  consequent  loss  of  sleep,  but  there 
*  are  no  characteristic  constitutional  symptoms.  Leucorrhea  may  be* 
'  tlie  only  symptom. 

Diagnosis*— The  patient  is  in  the  8ims  position.  A  Sims  specu- 
lum is  employed.  It  is  noted  tliat  the  vagina  is  not  sensitive  as 
in  the  acute  stage  and  does  not  feel  fiot  to  the  examining  finger. 
The  mucous  membrane  is  thickened  and  is  of  a  dark  reil  or  bluish 
color;  in  places  it  is  smooth  and  in  others  it  is  roughened  and  the 
discbarge  is  thinner  and  less  purulent  than  in  the  acute  stage. 


A 


366  DISEASES  OF  THE  VAGINA 

It  is  to  be  remembered  that  the  vagina  may  be  simply  a  canal 
which  conducts  purulent  or  other  fluids  from  the  uterus  or  the 
surrounding  organs  to  the  vulva;  therefore  be  sure  that  the 
inflammatory  process  is  primary  in  the  vagina.  In  the  case  of 
gonococcus  infection,  as  pointed  out  already,  the  process  is  second- 
ary to  infection  in  the  urethra,  Bartholin's  glands,  and  the  cervical 
canal;  conseciuently  those  situations  should  receive  attention. 

The  special  varieties  of  vaginitis  just  enumerated  should  be 
borne  in  mind  and  their  characteristics  recognized.  Cultures 
and  smears  are  made  from  the  discharges  and  pieces  of  tissue 
removed  for  microscopic  examination  in  all  doubtful  cases. 


DISPLACEMENTS  OF  THE  VAGINA 

In  this  section  we  shall  consider  cystocele,  rectocele,  and  the 
rare  condition  known  as  true  heniia  of  the  vagina. 

Cystocele 

Cystocele  is  a  prolapse  downward  of  the  anterior  wall  of  the 
vagina  together  with  the  base  of  the  bladder.  It  would  appear 
that  in  some  cases  the  muscular  wall  of  the  vagina  has  given  way 
and  the  bladder  wall  in  the  cystocele  is  covered  only  by  vaginal 
mucosa.  If  the  urethra  alone  is  dislocated  downward  the  con- 
dition is  called  urethrocele.  In  this  case  the  urethra  may  be  detected 
as  a  thickened  ridge,  and  passage  of  the  sound  together  with 
palpation  shows  the  situation  of  the  urethra. 

Etiology  and  Frequency. — The  chief  cause  of  cystocele  is  child- 
bearing,  the  anterior  movable  segment  of  the  pelvic  floor,  that 
portion  lying  betwcH>n  the  arch  of  the  pubes  and  the  uterus  (see 
Chapter  XIII,  Etiology  of  Prolapse,  page  223)  being  dislocated 
and  stretched.  Injuries  of  the  perineum,  actual  tears  of  the 
anterior  vaginal  wall,  and  subinvolution  of  the  vagina  are  con- 
tributory causes.  Ru[)ture  of  the  perineum  and  consequent  lack 
of  support  to  the  anterior  wall  of  the  vagina  is  an  important 
factor  in  the  causation.  Cystoc(*le  is  most  often  met  with  in 
working  women  who  have  less  careful  obst(^tric  supervision  than 
the  women  of  the  upper  classics,  and  get  on  their  feet  before  involu- 


DISPLACEMENTS  OF  THE   VAGINA 


mi 


tioii  of  the  utoru«,  vagina,  and  perineum  have  Ix^n  conipletinL 
As  injuries  of  the  perineum  and  jx^lvic  floor  are  ilie  ehief  cause 
of  siibinvohition  it  behooves  the  physician  to  diagnose  and  repair 
theise  injuries  promptly  and  tluus  [*revent  the  oeeurrence  of  cysto- 
cele,  which  may  not  develop  for 


'/i 


monthly  or  years  after  the  re- 
ceipt of  the  injuries. 

Symptoms. — The  symptoms 
depc^nd  on  the  extent  of  tht^ 
|>rolapse.  They  are,  a  sensa 
tion  of  fuilnetss  in  the  orifice  of 
the  vagina,  and  the  feeling  that 
soinetliing  projects  in  that  sit- 
uation on  straining,  the  bulg- 
ing cystocele  being  mistaken 
for  uterine  prolapse;  also  drag- 
ghig  and  weight  in  the  pelvis, 
in  the  ca^e  of  large  eystocele 
and  proIapse%  and  inability  to 
empty  tlie  bladder  easily.  If 
the  urethra  is  dislocated 
(urethi'oeele)  there  is  more  or 
less  incontinence  on  coughing, 
laughing,  and  straming.  There  may  Ix"  residual  urine  in  a  dislo- 
cated bladder  with  corusequent  cystitis.     This  is  rare. 

Diagnosis. — There  may  or  may  not  be  evidence  of  bulging  of 
the  anterior  wail  of  the  vagina  when  the  introitus  vagina?  i» 
inspected  with  th<^  patient  in  the  dorsal  position.  Straining  brings 
the  anterior  wall  irito  view,  however,  A  curved  sound  urtrodurrd 
through  the  urc*tlira  show.s  the  situation  of  the  base  of  the  bla<liler 
as  determinetl  by  pa!j)ation  of  its  tip  under  the  anterior  vagijial 
wall.  The  extent  of  the  pnjlapse  may  Ixi  estimated  by  examining 
the  patient  in  the  standing  position  and  asking  her  to  strain  while 
the  oxaminatii^n  is  made.  In  the  knet-^clK^t  position  the  cystocele 
diaappeai'S.  In  large  cystweles  the  vaginal  wall  is  thickened  and 
lias  the  appearance  of  skin.  In  prolapse  of  the  uteras  it  may  be 
ulcerated* 

DiiSfereotial  Diagnosis,— We  tTiust  flistinguish  eystocele  from 
cyst  or  other  tumor  of  the  vagina,  hypertropliy  of  the  bladder 


I  -li^.  — K   Vfit<Jtvlc 


368 


DISEASES  OF  THE  VAGINA 


wall  in  chronic  cystitis,  sub-urethral  abscess,  and  true  intestinal 
hernia  of  the  vagina.  Tumor  of  the  anterior  vaginal  waU  does  not 
increase  in  size  or  tension  on  straining  and  coughing,  it  does  not 
disappear  on  pressure  or  on  putting  the  patient  in  the  knee-chest 
position,  filling  the  bladder  has  no  effect  on  the  size  or  elasticity 
of  the  tumor,  and  palpation  of  a  sound  in  the  bladder  shows  that 
there  is  something  besides  the  walls  of  the  bladder  and  vagina 
between  the  tip  of  the  sound  and  the  examiner's  finger  in  the 
vagina. 

Hypertrophy  of  the  bladder  uxdl  in  chronic  cystitis  to  the  extent 
of  forming  a  tumor  in  the  vagina  is  rare.  The  diagnosis  of  cystitis 
by  means  of  the  cystoscope  and  examination  of  the  urine,  together 


Fig.  148a. — Diagrammatic  Representation  of  Cystooele. 

with  the  symptoms  of  cystitis,  point  the  way  toward  a  differentia- 
tion. Palpation  of  the  greatly  thickened  bladder  by  the  finger 
in  the  vagina  will  settle  the  diagnosis. 

Sub-urethral  abscess  is  diagnosed  by  placing  a  sound  in  the 
urethra  and  palpating  the  tumor  in  the  vagina  on  the  sound. 
In  this  way  it  will  be  plain  that  the  urethra  is  not  involved  in  the 
tumor.  Besides,  there  are  present  in  the  case  of  the  abscess  symp- 
toms and  signs  of  inflammation,  and  there  is  apt  to  be  a  minute 
opening  of  the  abscess  into  the  urethra  through  which  pus  may 
be  forced  on  pressure. 

Anterior  intestinal  vaginal  hernia  is  a  rare  condition  in  which 


DISPLACE5IENTS  OF  THE   VAGINA 


369 


coils  of  small  intestine  occupy  a  sac  formed  by  a  pouch  of  pro- 
lapsed peritoneum  between  the  front  of  the  uterus  and  the  bladder. 
Thi>s  poucli  projects  under  tlie  anterior  vaginal  wall  in  the  same 
situation  a.s  a  cystocele.  '  On  pres^sure  a  true  hernia  disappeans 
with  a  gurgling  sound,  it  disappears  when  the  patient  is  in  the 
knee-chest  position,  it  is  soft  and  doughy  to  the  touch,  and  the 
coils  of  intestine  may  be  palpated  between  a  sountl  in  tlie  bladder 
and  a  finger  in  the  vagina,  tlius  showing  a  greater  thickness  of 
the  intervening  structures  than  in  the  case  of  cystocele. 


Regtocele 

Ilectoeele  is  a  forward  protrusion  of  the  anterior  rectal  wall 
into  the  vagina,  although  the  name  is  given  to  any  !>ulging  of  the 
posterior  vaginal  wall,  whether  the  protrusion  rontauis  the  rectum 
or  not.  It  is  possible  for  the  posterior  vagina  to  become  separated 
from  the  rectal  wall,  Ix^cause 
of  the  loose  comiection  of  the 
two  structures.  As  a  rule  the 
rectal  wall  is  in  the  dislocated 
vagina.  Reetocele  is  one  of 
the  concomitants  of  complete 
uterine  prolapse. 

Etiology  and  Frequency* — 
Reetocele  is  eausetl  by  rupture 
of  the  jx^rineum  and  pelvic 
floor,  by  consequent  subinvo- 
lution of  the  vagina,  and  by 
chronic  overdistention  of  the 
rectum  by  feces  and  scybalous 
masses. 

The  firm  support^  ordinarily 
given  to  the  anterior  wall  of 
the  rectum  during  defecation, 
due  to  contraction  of  the  levator  ani  muscle  at  this  time,  is  lacking 
because  of  the  injurj^  of  this  naiscle.  Therefore  the  fecal  mass 
covered  by  rectal  and  vaginal  walls  is  jjushed  forward  into  the 
vagina.  Constant  straining  accentuates  the  faulty  condition. 
Like  cystocele,  the   development  of  a  reetocele   is  a  matter  of 


149.— Hectoct'li\ 


370 


DISEASES  OF  THE  VAGINA 


months  and  years,  and  the  disease  is  frequent  among  the  working 
classes  for  the  same  reason  as  in  the  case  of  cystocele. 

Symptoms. — ^The  symptoms  are  a  sense  of  fullness  in,  or  pro- 
trusion from,  the  vulva,  weight  and  dragging  in  the  pelvis,  and 
difficulty  in  defecation.  Sometimes  the  woman  is  obliged  to 
replace  the  rectocele  with  her  fingers  before  she  can  empty  the 
bowel,  and  in  pronounced  cases  of  rectocele  there  is  apt  to  be 
rectal  tenesmus  and  a  feeling  as  if  the  rectum  had  not  been  emptied 
completely. 

Diagnosis. — Bulging  of  the  posterior  vaginal  wall  may  be  visible 


Fig.  149a. — Diagrammatic  Representation  of  Rectocele. 


on  separating  the  labia  when  the  patient  is  in  the  dorsal  position. 
Straining  brings  the  wall  into  view  and  it  recedes  again  when  the 
effort  is  over.  The  physician,  passing  a  forefinger  through  the 
anus,  hooks  it  forward  into  the  rectocele.  This  makes  positive 
the  diagnosis  and  differentiates  separation  of  the  posterior  vaginal 
wall  from  the  rectum,  from  cases  of  true  rectocele.  We  must 
rule  out  cysts  and  other  tumors  of  the  posterior  vaginal  wall  and 
true  posterior  vaginal  hernia  or  enterocele.  Both  of  these  are 
palpated  between  a  finger  in  the  rectum  and  another  finger  in  the 
vagina.  A  cyst  or  tumor  is  fluctuating  or  hard,  and  is  felt  as  a 
distinct  mass  betwec^n  the  two  fingers,  whereas  in  rectocele  the 
rectum  and  vaginal  walls  alone  are  lx»tween  the  fingers. 


INJURIES  OF  THE  VACilNA  371 

In  the  case  of  cnterocelo  the  rloy^liy  (vvl  (>f  intestine  with  trur- 
gling  on  pressure  is  to  be  made  out,  anrl,  on  placing  the  patient 
in  tlie  knee-cheat  position  the  tuinor  diHai>|x'ars5. 

Hernia  or  Enterocele 

True  hernia  or  the  descent  nf  h  loop  of  intestine  in  a  jioueh  of 
peritoneum  either  into  the  recto- vaginal  eellular  tis-sue  below 
Douglas'  cul-de-.«ac,  or  into  the  cellular  tissue  between  the  uterus 
and  the  blad<ler^  is  a  rare  occurrence.  It  is  sufficient  to  note  that 
eases  have  been  reported  and  that  the  diagnosis  is  made  by  pal- 
pating the  tumor  and  r-liciting  the  doughy  feel  eharaeterislie  of 
intestine,  by  noting  g\ngling  noisc^s  in  the  tumor  when  it  is  i)n*ssi*d 
upon,  and  by  observing  that  the  tuinor  increases  in  size  on  straining, 
but  disap|>cars  when  the  patient  is  plaeeil  m  the  knee-chest  position. 
Such  tumons  must  Ix*  differentiated  carefully  from  reetocele, 
cyhtocele,  or  tumor  of  the  vaginal  wall.     (Set*  tliese  sections/) 

In  very  rare  cases  an  enterocele  has  Ik'cu  know^i  to  find  its 
way  to  the  vulva.  In  this  situation  it  iinist  b*  distinguislied  from 
inguuial  hernia  tliat  hfLS  reached  the  labium  majys.  Examination 
of  tiie  external  alKlominal  ring  will  show  whi^ther  the  ring  is  free. 
Also  it  is  to  bt^  differc^ntiated  from  a  cy^t  of  Bartholin's  gland  or 
other  tinnor  of  the  labium.  In  the  ease  of  the  enterocele  it  has  an 
origin  from  alxive,  has  an  impulse  on  coughuig,  and  ilisa|jpears 
w  it  h  the  patient  in  the  knee-chest  position,  A  tumor  of  the  labium 
has  none  of  these  characteristics. 


p 


INJURIES  OF  THE  VAGINA 


Injuries  of  tlu*  vagina  may  U*  <iue  In  (1)  child! rearing,  tn  ttM> 
rapid  exjjulsion  of  the  head^  breech,  or  shouklers,  or  to  pressure 
of  tlie  blailes  of  forceps^  (2)  to  coitus,  wiiere  there  is  disf)roimrtion 
betw^t^n  the  size  of  the  penis  and  the  vagina,  ami  too  great  violence 
is  usi-il,  (3)  to  miskillful  instrutiientation,  and  (4)  to  a  fall  on  a 
sliarp  Ivwly  such  as  a  picket. 

(i)  Child  bearing. — A  majority  of  injuries  due  in  ehildlx»aring 
consist  of  lacerations  of  the  ])erinenni,  next  in  frequency  are 
lacerations  of  the  ut>[jer  vagina,  tlue  to  the  extension  of  a  tear  of 
the  cervix  to  the  vagina,     t^ometimes  a  circular  laceration  in  the 


^ 


d 


372  DISEASES  OF  THE  VAGINA 

upper  vagina  may  separate  the  cervix  partially  or  wholly  from 
the  vagina.  Generally  the  tears  of  the  vagina  are  longitudinal  in 
direction.  On  one  occasion  I  repaired  immediately  after  a  version 
an  extensive  longitudinal  laceration  of  the  anterior  vaginal  wall 
not  involving  the  cervix.  Lacerations  of  the  vagina  are  more  apt 
to  occur  where  the  vaginalVall  has  been  narrowed  by  cicatrices 
or  its  elasticity  has  been  impau-ed  by  disease. 

Lacarations  of  the  Perineum  and  Pelvic  Floor. — ^By  this  term  is 
meant  not  only  injuries  of  the  perineal  body  so-called, — ^really  not 
an  anatomical  entity, — but  also  damage  to  the  structures  compos- 
mg  the  pelvic  floor.  These  are  the  levatores  ani, — sphincter  vaginap, 
sphincter  ani,  and  transversus  perinei  muscles,  and  the  following 
fascia) :  posterior  layers  of  the  triangular  ligament, — called  also 
the  transverse  perineal  septum,  a  strong  mass  of  connective  tissue 
and  elastic  tissue  in  which  the  muscles  are  inserted,  the  anal  fascia, 
the  recto- vesical  fascia,  and  the  deep  superficial  fascia. 

By  conjoined  recto- vaginal  examination  of  a  nullipara  one 
determines  that  the  tissues  between  the  fingers  are  of  the  shape 
roughly  of  a  triangle,  with  its  slightly  convex  base  the  space  on  the 
skin  between  the  anus  and  the  fourchette,  and  its  apex  at  the 
upper  limit  in  the  vagina  of  the  lower  anterior  curve  of  the  S 
formed  by  that  canal  in  its  course  to  the  cervix.  The  tissues  feel 
firm  and  elastic  (the  transverse  perineal  septum)  and  there  is  a 
distinct  convexity  upward  (the  patient  being  in  the  dorsal  position) 
of  the  lower  posterior  vaginal  wall. 

An  attempt  to  evert  the  rectum  through  the  opening  of  the 
vagina  will  encounter  much  resistance  and  cause  pain  to  the 
patient.  If,  now,  the  patient  is  asked  to  strain  it  is  noted  that 
the  anterior  and  posterior  walls  of  the  vagina  already  in  contact 
are  pressed  more  firmly  together  and  that  the  perineum, — the  skin 
surface  between  the  vagina  and  rectum, — bulges  outward,  and 
the  distance  between  anus  and  fourchette  is  increased.  If,  on 
the  contrary,  the  woman  is  told  to  draw  in  the  muscles  it  will  be 
found  that  the  anus  and  the  skin  perineum  are  lifted  inward 
and  upward  toward  the  posterior  surface  of  the  arch  of  the 
pub(\s. 

By  vaginal  palpation  pressure  directed  backward  and  on  both 
sides  of  the  middle  line  encounters  definite  elastic  resistance  (the 
levator  ani  muscles).    If  the  patient  is  asked  to  contract  the  mus- 


INJURIES  OF  THE    VAGINA 


cles  they  are  felt  to  Iwrnmr  rigitl.  The  significance  of  a  laceration 
depends  on  the  nuiulxT  of  structui'es  involved  and  on  the  extent 
of  the  injury. 

In  most  first  labors  there  is  some  injury  of  tlie  fourvlietto  in  the 
metlian  line.  These  sufierficial  tt^arr^  are  of  little  practical  iniiJ^jr- 
tance  because  they  clo  not  involve  the  supporting  Btmetures  of 
the  pelvic  flevor.     If  t!ie  structures  composing  the  ptTineum  are 


vl»v^* 


Fig.  150. — Diagmmmatic  Lofipttjdinal  5Ie<:liaii  Section  of  the  Pelviu,  Showing 
Stnjctures  uf  the  Pelvic  Floor,     (Dickinson.) 


rigifl  and  non-ela'^ic,  as  in  the  ease  of  oM  primiparap,  the  tear  is  apt 
to  be  deeper  and  therefore  of  more  si^rious  iinpoil. 

Tears  of  the  pelvic  Hoor  proper  are  of  three  sorts:  (a)  median, 
(6)  lateral  in  one  or  both  sulci,  and  (c)  a  combtnation  of  these 
two. 

(a)  Median  tears,  if  of  any  considerable  depth,  are  apt  to  involve 
the  spWncter  ani  muscle  to  a  greater  or  less  degree.  To  put  the 
case  a  little  difTert*ntly,  a  vast  majority  of  the  lacerations  of  the 


374 


DT8K\SES  OF  TITE  VAGINA 


sphinrter  aiii  aro  mfilian  tears.  In  tin*  rasv  of  rninjjlete  laceration 
uf  ihv  perineum  the  iH^lvie  Hoor  prn|)(M-  is  not  injured  to  the  extent 
that  its  8Ui>|iorting  {jowi*r  is  li's.sinit'd,  tlierefore  we  do  not  exiH*et 
to  find  the  results  of  laceration  of  the  pelvic  floor  m  the  form  of 
cystoeele^  retroversion,  and  j>rolaj)se. 

Partial  or  complete  los8  of  control  over  the  bowels  is  to  be  ex- 
p**ctrul  after  laeiTation  of  the  sphincter  ani.  If  only  a  portion  of 
the  fillers  of  the  si>hincter  are  in juhmI  tlie  patient  may  lx.»  able  to 
control  her  bowels  if  they  are  constipated,  but  not  if  they  are  loose; 
or  the  retentive  power  over  gas  may  be  lost. 

Complete  iMceratiitn. — ^Su|>i>nse  the  laceration  is  comi>ltHc. 
Inspe^ction  shows  a  gai)ing  vulva  with  the  retracted  ends  of  the 


FiG.  151* — Cojiipk'te  iltMiiau  Laix^ralmo  of  the  Ferint^iim.     Levator  Ma  My,^^,*  - 
not  Injured.   (GilUam,) 

sphincter  ani  mnselc  showing  as  a  minute  dimple  on  each  side 
of  the  anus  at  the  ends  of  the  contracted,  crescentic  muscle.  Tht* 
recto-vaginal  sr^ptum,  when  not  extensively  torn,  stretches  al>ov<* 
as  a  teni^^  l)an<i  across  thi^  open  anus,  in  which  the  bright  red 
corrugated  mucosa  of  tht^  rectum  is  seen.  Unless  the  levator  ani 
has  l>een  injured »  the  walls  of  the  upper  vagina  an?  in  contact. 
If  the  laceration  has  not  Ix^en  comiil(»te  a  fingiT  inserted  into  the 
anus  estimates  the  amount  of  damage  to  the  sphincter  by  noting 
the  strength  with  which  it  gra^tps  the  finger 

(6)  and  (c).     Lateral  tears  in  the  sulci  are  the  common  forms 


i 


of  injury  to  tlic  {irlvir  ihmr.  They  art'  the  important  ones  from 
the  point  of  view  of  the  ditsiocation  ami  diseases  of  the  |>e]vie 
organs  whieli  result  if  they  are  not  rejjaired. 

The  lateral  tears  injure  the  levator  ani  nuiscle.  After  the  injury 
the  muselc  ends  contract  and  carry  with  them  the  torn  faseiie; 
s^jme  of  the  injured  structuirs  are  replacfnl  by  eonneetive  tissue, 
and,  in  the  case  of  tears  reaching  the  surface^  by  cieatrieial  tissue. 
In  the  course  of  many  years  there  may  Ik*  marked  atrophy  of  all 
the  stmetures  composing  the  pehnc  floor.  The  exact  kind  of 
deformity  that  results  in  any  given  case  is  determined  by  the 


Fig.   152,— IVrincuri!   Lacoratt'^i 


in   liuth  Sulci 
((iiliiam/) 


Levator  Am  Musclos  InjunMi. 


structures  involved  and  the  time  which  hiis  ela|)sed  since  the 
receipt  of  the  injury.  Sundering  the  transverse  perineal  septum 
pemiits  the  transversus  perinei  muscles  to  contract  and  draw 
the  edges  of  a  wound  to  f»nth  sides  of  the  \^i!va.  At  an  exami- 
nation of  a  fresh  tear  in  the  hours  following  delivery  it  is  possible 
to  get  a  fairly  accurate  idea  of  the  structures  involve*!,  alth<jugh 
the  swelling  ami  distortion  r>f  the  tissues  at  this  time  nwler  the 
determination  not  easy.     By  s<.»parating  the  labia  ami  sponging 


376  DISEASES  OF  THE  VAGINA 

ofif  the  blood,  the  difference  between  the  shining  vaginal  mucosa 
and  the  oozing  raw  tissue  becomes  apparent.  The  anterior  vaginal 
wall  should  be  held  up  against  the  pubes  and  the  tears  traced  to 
their  farthest  limits.  With  a  finger  in  the  rectum  the  upper  por- 
tions may  be  brought  better  into  view.  A  good  light  and  the 
patient  on  a  table  or  on  an  ironing  board  on  the  edge  of  the  beil 
are  essentials  to  an  exact  diagnosis.  After  an  interval  of  months 
and  years  we  can  not  say  exactly  what  has  occurred  at  the  time 
of  injury.  Dissection  on  the  living,  in  the  course  of  an  operation 
undertaken  for  the  purpose  of  repair,  will  not  give  us  this  informa- 
tion because  of  the  abundant  blood  supply  of  the  parts  involved. 
Inspection  of  an  old  laceration  in  the  sulcus  shows  a  gaping  vulva, 
vaginal  walls  apart,  perhaps  cystocele,  rectocele,  or  prolapse,  the 
perineum  is  flat  and  longer  than  normal  because  the  rectum  is 
displaced  backward.  When  the  patient  strains  the  vaginal  walls 
roll  down  instead  of  holding  closer  together,  and  the  perineum 
between  the  fourchette  and  anus,  instead  of  bulging,  is  con- 
cave. Palpation  shows  a  groove  in  the  sulcus  and  a  lack  of  hard- 
ness here  when  the  patient  contracts  the  muscles  of  the  pelvic 
floor.  The  perineal  septum  is  always  more  or  less  injured  in 
these  cases,  and  palpation  of  the  perineum  with  one  finger  in  the 
vagina  and  the  other  in  the  rectum  will  make  manifest  that  the 
convex  summit  of  the  perineal  body,  the  top  of  the  anterior  S 
curve  of  the  lower  vagina,  has  disappeared  and  in  its  place  is  a 
depression.  In  many  cases  very  little  injury  is  apparent  when  the 
vulva  is  inspected  because  the  skin  has  not  been  severed.  The 
physician  should  be  on  the  lookout  for  the  "skin  perineum"  and 
not  be  deceived  by  it.  By  hooking  a  finger  into  the  vagina  the 
absence  of  the  firm  convex  surface  of  the  perineum  will  be  appar- 
ent at  once.  A  common  form  of  laceration  is  a  tear  in  one  sulcus 
together  with  a  tear  in  the  median  line. 

By  the  former  we  assume  that  the  levator  ani  is  injured  and  by 
the  latter  the  transverse^  perineal  septum.  Often  both  sulci  are 
affected  and  there  is  also  a  tear  in  the  median  line  below.  Too 
much  can  not  be  said  of  the  importance  of  making  an  exact  diag- 
nosis of  the  situation  of  the  tear  in  every  case  of  rupture  of  the 
pelvic  floor,  for  in  this  way  only  can  repair  be  intelligently  carried 
out. 

(2)  Injuries  due  to  coitus  are  not  frequent.    Sometimes  the  first 


FOREIGN  BODIES  IN  THE  VAGINA 


377 


coitus  causes  a  laceration  of  the  hymen  which  extends  to  the  vagina 
and  there  niay  be  serious  hemorrhage.  KaiK^  hai>  caused  severe 
and  fatal  injury  of  the  vagina  in  children  and  also  in  women.  In 
willing  coitus  whenever  there  is  a  large  penis  and  a  small  vagina 
injury  may  occur  if  force  is  used. 

(5)  Injuries  due  to  unskiEful  instrumentation  are  not  very  un- 
common. The  violence  is  done  soinetinies  by  the  patient  intro- 
ducing sharp  instruments  into  the  vagina  in  an  vffoit  to  produce 
alx)rtion,  and  at  others  by  the  ignorant  abortionist,  also  the  un- 
skillful use  of  the  obstetric  forceps  or  other  instruments  may  cause 
laceration,  oftcni  of  serious  import. 

(4)  Falls  on  sharp  bodies^  such  as  the  picket  of  a  fence  or  the 
handle  of  a  pitchfork,  have  produced  extensive  and  even  fatal  in- 
jm-ies. 

Hematoma  of  the  vagina  is  a  rare  condition.  It  occurs  both  as  a 
result  of  trauma  and  following  labor,  the  latter  being  by  far  the 
more  frequent  cause.  There  is  a  collection  of  blood  just  under  the 
mucous  mendjrane  and  the  tumor  is  dark  in  color  and  fluctuates. 


I 

I 


FOREIGN  BODIES  IN  THE  VAGINA 

Little  girls  may  introduce  foreign  bodies  in  the  vagina,  just  as  in 
the  other  accessible  ca\ities  of  the  body,  from  a  spirit  of  inquisi- 
tiveness.  Thus  pebbles,  seetls,  fruit- stones,  i>encils,  hairpms,  and 
other  objects  have  been  removed  from  the  vaginte  of  little  girls. 
Older  girls  and  women,  esj>ecially  the  sexually  perverted,  have 
introduced  the  ends  of  canttles,  pencils,  and  other  things  for  pur- 
pascs  of  masturbation.  S{^^>f)ols,  rul:>l>i^r  balls,  sponges,  pieces  of 
cotton,  and  many  other  suKstances  have  bef*n  taken  from  vagina^  in 
which  they  ha^j  Imm  placed  in  the  hojje  of  preventing  conception. 

The  vagina  has  s<*rveil  as  a  repository  for  smuggled  and  stolen 
property,  such  as  jew(4ry,  gems,  and  banknotes,  and,  in  tlie  case  of 
the  feeble-minded,  a  legion  of  strange  articles  have  been  secret^ 
there.  The  foreign  liody  most  often  found  in  the  vagina  is  a  neg- 
lected or  forgotten  pessary.  As  is  well  knowTi,  a  hanl- rubber 
pessary  becomes  incrusted  with  lime  salts  as  soon  as  its  pf»Iish  is 
gone.  The  roughened  surfact*  chafes  the  mucous  membrane  until  it 
ulcerates,    Soft-mbber  pessaries  irritate  the  vagina  more  than  the 


378  DISEASES  OF  THE  VAGINA 

hard-rubber  variety,  as  a  rule,  but  not  being  so  firm  do  not  cut  so 
far  into  the  tissues.  Pessaries  have  been  retained  for  a  long  series 
of  years  in  reported  cases,  and  sometimes  with  resulting  stenosis  of 
the  vagina.  Sometimes  a  vesico-vaginal  or  a  recto-vaginal  fistula 
is  caused  in  this  way.  Pin  worms  and  round  worms  may  inhabit 
the  vagina.  There  is  a  foul  discharge  from  the  vagina  if  ulceration 
is  present.  The  diagnosis  of  a  foreign  body  is  an  easy  matter  when 
digital  and  speculum  examination  are  made,  attention  having  been 
attracted  by  the  vaginal  discharge. 

Gas  in  the  Vagina  (Garrulity  of  the  Vagina.) — An  accumulation  of 
gas  in  the  vagina  that  is  expelled  with  a  noise  on  straining  or  moving 
the  body  quickly  from  one  position  to  another  is  a  not  very  rare 
condition.  Every  gynecologist  of  experience  has  seen  many  cases. 
In  the  past  it  has  been  thought  that  such  a  condition  was  due  ex- 
clusively to  injuries  to  the  pelvic  floor,  so  that  in  certain  positions 
of  the  body,  as  on  the  side,  air  entered,  to  be  expelled  later  when 
the  woman  assumed  the  upright  position.  Although  such  a  cause 
may  be  operative  in  some  easels,  the  recent  investigations  of  Klein- 
wachter,  Taussig,  and  Veit  (**Handbuch  der  Gynakologie,"  zweite 
Aufl.,  Bd.  Ill,  page  201)  go  to  prove  that  the  accumulation  of  gas 
in  the  vagina,  a  condition  most  often  found  in  the  puerperium,  is 
due  to  a  gas-foiming  bacterium.  The  disease  is  thought  to  be  alliwl 
to  vaginitis  eni{)hysematosa  (see  page  36i)  and  has  been  classeil  by 
Veit  as  among  the  inflammations  of  the  vagina. 

When  the  disease  is  due  to  injury  of  the  pelvic  floor  with  subin- 
volution coupled  with  weakening  of  the  abdominal  walls,  the  diag- 
nosis is  not  so  difficult.  If  those  conditions  do  not  obtain,  and  it  is 
due  to  a  gas-forming  organism,  drying  the  vagina  and  packing  it 
with  dry  tampons  on  which  boric  acid  powder  has  been  dusted 
will  kill  the  organism  and  thus  confirm  the  diagnosis.  We  must 
rule  out  n^cto-vaginal  fistuUe  in  these  cases,  for  gas  in  the  vagina 
may  come  from  the  rectum. 

VAGINISMUS 

Vaginismus  may  Ix^  n^garded  as  a  symjitom  rather  than  a  disease. 
It  consists  of  a  liyp<T(\^tlietie  condition  of  the  orifice  of  the  vagina 
and  is  characterized  by  spasmodic  and  painful  contractions  of  the 
levator  ani  and  constrictor  vaginte  nmscles.    Sometimes  the  irri- 


NEW  GROWTHS  OF  THE  VAGINA 


379 


lability  extends  Uy  th<;  tiiuscles  of  the  thiglis  or  other  sets  of  mujseles 
in  the  neighlxjrhtxxl  of  the  vulva. 

Vaginistnus  is  a  rare  eonditiori  found,  as  a  rule,  in  yoiinp:t  neurotic 
women  and  in  tht^  ni^wly  marriiMl.  It  may  ovvui\  however,  in 
women  who  have  borne  children.  It  may  te  def>endent  on  a  local 
lesion,  such  as  urethral  earunele  or  inflammatiou  of  the  vulva. 
Masiurbation,  by  overstimulation  of  the  H*\ual  organs,  causes 
\'aginismus  in  some  instances.  I iK'ff tactual  atterripts  at  coitus  pro- 
duce in  time  erosions  at  the  introitas  and  nervous  excitability  and 
dread  of  pain.  A  large  penis  and  a  small  vagina  may  cause  tonic 
spasms  of  the  muscles  of  the  pelvic  floor.  Castas  are  on  RTOrd  where 
the  [xmis  has  become  im])risoiKMl  in  the  vagina  by  vaginismus  so 
that  it  was  necessary  to  administer  an  anesthetic  to  the  woman 
lx*fore  the  couple  coukl  Ix'  separated.  The  vagiim  may  be  very 
sensitive,  so  that  the  slightest  touch  or  even  takhig  a  douclie  causes 
contraction  of  the  muscles,  and  a  vaginal  examination  is  impossible 
without  an  anesthetic,  or  it  may  be  caused  only  by  violent  inter- 
course. The  nervous  system  sufl'ers  when  vaginismus  has  existed 
for  any  length  of  time  and  various  nerv^ous  stigmata  may  Iw 
present.  A  vaginal  examination  will  deterrnine  the  cause  of  the 
condition.  If  necessary  a  Seconal  examinati<m  with  an  anesthetic 
must  be  made.  Vagiiiismus  is  one  of  the  causes  of  dyspareunia,^ 
painful  coitus.    (See  Chapter  X.,  page  146.) 


NEW  GROWTHS  OF  THE  VAGINA 


The  new  growths  of  the  vagina  are:  (1)  cysts,  (2)  myomata,  (3) 
sarcomata,  (4)  carcinomata. 

(i)  Cysts.— Cysts  of  the  vagina  are  the  mast  frequent  of  the 
tumors  found  in  this  organ.  As  a  rule^  they  art*  f>etween  the  size  of 
a  jR^a  and  an  English  walnut,  are  single,  and  found  on  the  anterior 
rathiT  than  on  the  posterior  wall.  Very  large  c}i?ts  may  develop 
in  exceptional  instances,  and  in  such  cases  the  cyst  develops  in  the 
broad  ligament;  very  rarely  a  series  of  cysts  is  found.  A  cyst  of 
the  vjigina  ajipears  as  a  l>luish- white ^  roimded  eminence  in  the 
pink  mucous  membrane  of  the  vagina.  It  is  elastic  to  the  kx^h  If 
the  cygft  is  situate<!  superficially  it  projects  more  into  the  lumen  of 
the  vagina  and  is  of  a  darker  color  liecause  of  its  thin  waOs:   if  it 


380 


DISE.\SES  or  THE  VAGINA 


m^ 


is  situated  deep  in  ihv  vaginal  wall  it  projects  less  pronimently  and 
is  not  so  dark  in  color. 

Cysts  of  the  vtigina  mv  due  to  (a)  inclusions  of  epithelial  tissue 
during  o{>eration8  for  the  repair  of  lacerations  of  the  perineum, 
or  during  spontaneous  healing  of  8ueh  Injuries;  (6)  vaginal  gland 

tissue,  and  (c)  the  remains  of  embryonic 
struotures,  such  as  Gartner's  and  Miii- 
ler's  ducts.  Tlie  inclusion  cysts  are 
generally  found  in  the  mughbirhood  of 
the  ptTineuiH,  in  the  posterior  wall,  low 
down.  These  ai'e  .small,  spherical  in 
s!ia[>e,  have  as  contents  mucus  made 
turbid  by  desijuamate^d  epithelium,  and 
are  lined  with  a  layer  of  stratified 
s<iuanioys  epithelium.  Not  much  is 
knoi^ii  about  tlie  cysts  which  arise 
from  vaginal  gland  tissue.  They  are 
m frequent  as  compareil  with  the  other 
two  varieties,  however.  Cysts  originat- 
ing in  pc^rsistent  Gartner's  ducts  are 
conii>aratively  frequent,  and  are  situ- 
ated in  the  lateral  or  anterior  walls  of 
the  vagina.  These  cysts  are  more  apt 
to  be  cylindrical  in  shape  than  per- 
fectly gloluilar,  corresponding  b  their  Icjug  axis  to  the  axis  of  the 
duet,  arc  filled  with  a  clear  straw-colored  fluid,  and  are  lined 
with  cylindrical  epithelium. 

A  perststf^nt  Milller's  du(*t  has  k^en  referreil  to  in  the  chapter 
on  anomalies,  A  blinil  end  of  a  misplaceil  ureter  has  been  known 
to  form  a  cyst  of  the  vagina. 

The  diagnosis  offers  little  difficulty.  C}'st.ocele,  urethrocele,  and 
rectocele  must  Ije  rulei!  out,  also  other  tumors  of  the  vagina.  An 
arterio-venous  aneurism  has  teen  mistaken  for  a  cyst  of  tlie  vagina, 
also  vaginal  hernia,  or  eol lection  of  blood  in  a  double  vagina.  A 
sound  in  the  urethra  or  bhidder  wiJl  assist  in  excluduig  urethrocele 
and  eystocele,  and  a  finger  in  the  rectum,  rectocele. 

A  eystocele  or  rectoc<4e  should  increase  in  density  on  straining, 
whereas  a  cyst  does  not.  A  vagina!  hernia  should  transmit  an 
impulse  on  coughing  and  lias  a  characteristic  doughy  feel.    It  tlis- 


Fic3.  153. — Tndusion  Cyst 
of  Vagina  Occurring  Three 
Years  after  Repair  of  a  Peri- 
neal Tear,     (Cnllen.) 


« 


I 


NEfW  GROWTHS  OF  THE  VAGINA 


381 


?V 


appears  when  the  patient  is  placed  in  the  knee-chest  position.  An 
aneurism  should  have  a  tfirill.  Tlit*  characteristics  of  double  vagina 
have  bx'n  d<*^cribed  in  the  .seetii»n  on  anomalies. 

Ecliinoeoi'cus  cysts  of  t  lie  vagina  are  very  rHi*c  and  are  generally 
tlue  to  echinocoecus  colonies  in  the 
messometrimn     burrowing    in     the 
rectn-vaginal  septum. 

(2)  Myomata. — Myomata  or  fi- 
broids of  the  vagina  are  rare. 
Some  seventy  authentic  cases  have 
been  rt*pcjrted  in  the  hteratm-e,  being 
found  in  most  cases  in  women  Ix*- 
tween  forty  ami  fifty  years  of  age. 
They  occur  as  small,  s|iherical^  hard, 
nodular  tumors,  seldom  over  two 
inches  in  diameter,  projecting  from 
the  vaginal  wall  into  its  lumeru 
They  are  usually  single,  but  may  Ik* 
multiple  and  are  not  associated  witli 
fibroids  of  the  uterus,  although  a 
case  where  Ijoth  existeil  in  the  same 
patient  has  tx^en  n^ported  by  Fabri- 
cius  (ZeniralblaU  fur  Gynakolmjie^ 
1908,  No,  m,  1191)  and  another  by 
KelJy  and  CuUen  (*' Myomata  of  the 
Uterus^^*  page  440).  The  tumor  is  sessile  and  has  a  tibrous 
capsule  of  its  own  se|)aratjng  it  from  the  surrounding  tissues. 

The  etiology  i*f  these  tumors,  just  as  in  the  case  of  fibroids  of  the 
uterus,  is  mikoown.  They  are  apt  to  be*  the  seat  of  etlematous 
degeneration. 

The  diagnosis  is  generally  easy,  the  fluctuating  character  of  a 
vaginal  cyst  serving  to  rlistioguish  it  from  a  myoma,  anil  in  the 
ease  of  sarcoma  and  carcinoma  the  mucous  membrane  covering 
the  tumor  is  involved,  whereas  in  myoma  it  is  not.  The  hard 
character  of  the  tumor  serves  to  distinguish  it  from  cystocele,  rec- 
tocele,  or  hemia. 

(3)  Sarcomata. — Sarcoma  of  tlie  vagina  Is  of  two  sorts,  {a) 
sarcoma  of  the  vagina  in  children^  and  (A)  sarcoma  of  the  vagina 
in  adults. 


W: 


Fto,  154, — Cyst  of  Anterior 
Vaginat  Wall  Probably  Due  to 
Occltiflion  of  G&rtaer's  Duct. 
(Cullen.) 


382  DISEASES  OF  THE  VAGINA 

(a)  Sarcoma  of  the  vagina  in  children  is  of  doubtful  etiology,  but 
has  bcc^ii  observed  very  soon  after  birth.  It  generally  develops  in 
the  first  year  of  life  and  is  fatal  within  a  year  or  two.  In  one  case 
reported  the  child  lived  to  be  six  years  old.  About  forty  cases  of 
this  disease  are  on  record.  The  disease  is  characterized  by  the 
development  of  vesicle-like  polypi  of  a  dark  red  (hemorrhagic)  and 
pinkish-gray  (translucent)  color,  arranged  in  racemose  clust<jrs. 
In  the  beginning  of  the  disease  the  first  appearance  is  a  polyp,  usually 
attached  to  the  anterior  wall  of  the  vagma.  In  five  out  of  the  six- 
teen of  the  twenty-six  cases  analyzed  by  Starfinger  ("Sarcom  der 
Vagina  bei  Kindem,"  1900)  however,  the  disease  began  on  the 
posterior  wall.  Its  surface  is  smooth  and  it  resembles  a  mucous 
polyp  of  the  uterus.  From  this  polyp  there  develop  in  the  course  of 
time,  weeks  or  months  or  even  years,  proliferations  of  cystic  pol)q)i 
until  they  fill  the  vagina  and  project  through  the  vulva.  The  disease 
is  apt  to  involve  the  bladder  at  an  early  date,  then  the  cervix  and 
uterus,  and  finally  the  peritoneum.  Metastases  are  infrequent,  the 
growth  extending  mostly  by  continuity  and  generally  forward  into 
the  bladder  and  peritoneum  and  not  backward  into  the  rectum. 
Histologically  the  growth  consists  of  round  and  spindle-shaped 
cells,  also  giant  cells  and  strijx^d  muscle  fibers.  The  diagnosis 
before  the  disease  has  progressed  extensively  is  very  difficult.  A 
vaginal  discharge  in  an  infant  should  lead  to  a  speculum  exami- 
nation, a  Kelly  cystoscope  with  a  reflected  light  being  the  best 
instrument  for  tliis  purpose. 

(b)  Sarcoma  of  the  Vagina  in  Adults. — Fifty-two  cases  of  this 
disease  are  on  record.  It  is  a  disease  of  later  adult  life,  few  of  the 
cases  Indng  under  forty  years  of  age.  Here,  as  in  the  case  of  the 
chikl,  the  disease  b(»gins  as  a  polyp  most  commonly,  although 
instances  of  its  starting  as  a  diffuse  infiltration  are  reported.  It 
appears  to  lie  latent  for  a  considerable  time,  just  as  with  the  child. 
The  j)rimary  lesion  may  be  on  either  wall  of  the  vagina,  and  it 
progn^sses  in  its  development  as  a  ring-like  infiltration  so  that  the 
vagina  is  narrowed,  or  it  grows  as  a  diffuse  tumor  of  one  wall. 
Ulceration  occurs.  The  disease  does  not  often  penetrate  the  vesico- 
vaginal or  recto-vaginal  s(^pta  or  extend  largely,  but  metastases 
to  other  organs  are  formed  relatively  early.  Plistologically  the 
tumor  is  madc^  up  of  small  round  cells,  spindle  cells,  and  giant  cells, 
but  not  striped  muscle  fibers.    Melanotic  sarcoma  has  been  report- 


NEW  GROWTHS  OF  THE  VAGINA 


383 


*h1  in  three  cases.  The  apix^arance  of  a  potyp  situatt^d  on  tlu' 
vaginal  wall,  usually  with  a  broad  base  and  of  hrni  consistency, 
should  excite  a  sus]>it'iori  of  san^onia.  Mirrnsrnjiic  rxuinination 
of  the  remo\t*(l  polyp  will  dit^tinguish  aarconia  from  myoma  or 
carcinoma. 

(4)  Carcinoma  of  the  Vagina. — Carcinoma  of  the  vagina  is  eec- 
omlary  to  cancer  of  thr  uteriLs,  ui  whii-h  evfiit  it  is  relatively  com- 
mon, or  it  i.s  primary,  when  it  is  comimrativc^y  rare.  iSchwarz 
observed  84  cases  of  primary  cancer  of  the*  vagina  among  35^807 
gj'Tiecological  patii*nts,  or  somt^thing  over  twotenths  of  one  |kt 
cent.  It  fornus  abjut  one  per  cent  of  all  carcinoniata  of  the  gen- 
erative organs.  Primary  cancer  oftiw  vagina  Is  a  dist^ase  of  advanci'd 
life,  but  nmy  occur  a.s  early  a.s  the  twenty-sixth  year;  it  occurs  only 
in  womi:n  wlio  have  borne  (diiitlren  and  is  more  often  fomul  in  the 
posterior  wall  When  seen  *^arly  it  is  a  no^lule  an  ineli  or  an  iiirh 
and  a  half  in  diameter,  Tlie  CMJges  art^  sharply  defint^l,  infiltratHi, 
and  injecttul  Thi'  surface  soon  becorntn?  necrotic  and  ulceralrd 
and  may  exJiil)it  ijajiillary  elevations.  The  noclule  is  firndy  t^m- 
be<ldcHl  m  the  surrtMinding  tissues  after  the  very  earliest  stages. 
The  disease  extenils  extremely  rapidly  Ixjth  sui)erricial]y  and  dei»ply, 
ami  if  the  lower  jjortion  of  the  vagina  is  infect(Hl  the  inguinal  lymph 
glantls  are  mvolved,  Tlie  ilisi-ase  tends  to  extend  to  the  reetum 
more  often  than  to  the  Ijlaikler  and  it  nmy  reach  to  the  vulva;  it 
originates  in  the  s<|Uumous  epitlielium  and  has  all  the  ehara<ier- 
istics  of  stfuamous-eelliHl  cancer  (siH^  Cancer  of  tlu^  Uterus.  |>ag(^  267), 

In  getting  a  s|>eeimen  of  tissue  for  niicrosfoiiic  examination  the 
dee[XT  tiasuc*s  must  Ix'  excised  bn^ause  the  superficial  portions 
consist  usually  of  inflammntory  products  only.  The  synjj4oins 
in  the  early  stages  are  bleeding  from  the  vagina,  on  coitus  espe- 
cially, also  a  watery  vaginal  discharge. 

In  making  the  diagnosis  we  must  rule  out  secondary  carcinoma 
of  tlie  vagina.  Tliis  is  done  by  discovering  cancer  of  the  eervix, 
cerv^ieal  canal  or  fviudus  uteri,  or  cancer  of  the  rectum  or  bhiddcT, 
Carcinoma  in  thes«:^  situations  must  bc^  rigidly  exchide-d  Ix'foi-e  piTi- 
nouncing  the  dist^ase  i)rimary  iu  ih(^  vagina.  Myoma  is  excludetl 
by  the  jihysical  a[jpearances  of  myoma  and  by  tlie  microscojx*.  If 
a  primary  caneerous  area  lies  lx4iind  a  stenosis  of  the  vagina  the 
diagnosis  is  more  tlifficult.  Inflammatif»ns  of  tin*  vagina  with  ul- 
cerations arc  differentiated  l>y  the  absence  of  infiltration  under  the 


384  DISEASES  OF  THE  VAGINA 

abcess.  If  an  ulceration  caused  by  an  ill-fitting  or  neglected  pessary 
does  not  heal  rapidly  a  portion  should  be  excised  for  microscopic 
examination. 

There  have  been  reported  a  case  or  two  of  primary  chorioepUhe- 
lioma  of  the  vagina,  and  venereal  warts  in  conjimction  with  condy- 
lomata of  the  vulva  occasionally  occur. 


FISTULiE  OF  THE  VAGINA 

An  opening  between  the  vagina  and  the  surrounding  hollow 
viscera  is  called  a  fistula.  Of  such  fistulsB  there  are  five  sorts: — 
(1)  Vesico-vaginal,  (2)  Urethro-vaginal,  (3)  Uretero-vaginal,  (4) 
Recto-vaginal,  and  (5)  Entero-vaginal.  The  last  is  extremely 
rare.  For  the  sake  of  completeness  we  must  mention  a  communi- 
cation between  the  vagina  and  a  pelvic  abscess,  or  the  peritoneal 
cavity,  openings  made,  as  in  the  case  of  (5),  filstula  into  the  in- 
testine, in  the  course  of  operations. 

Vaginal  fistulas  are  caused  by  sloughing  of  the  vaginal  walls 
due  to  prolonged  pressure  of  the  child's  head  during  labor,  by 
injuries  from  obstetric  instruments,  by  ulceration  due  to  pessaries 
and  other  foreign  bodies,  or  by  ulcerations  from  foreign  bodies  in 
the  bladder.  They  result  also  in  the  late  stages  of  carcinoma  of 
the  cervix,  vagina,  rectum,  and  bladder,  and  following  operations, 
especially  hysterectomy.  In  the  last  case  and  also  when  a  vesico- 
vaginal fistula  has  been  formed  by  operation,  nature  closes  the 
opening,  generally  in  a  short  time. 

Vesico-vaginal  fistula  is  the  most  frequent  of  all  the  forms  of 
vaginal  fistulse,  although  not  nearly  so  often  met  with  as  in  the 
olden  days  before  the  art  of  obstetrics  had  been  perfected  to  its 
present  high  degree  of  excellence.  The  vaginal  and  bladder  walls 
are  involved  in  varying  extent.  Almost  the  entire  base  of  the 
bladder  may  slough  away,  leaving  the  orifices  of  the  ureters  exposed 
in  the  edge  of  the  fistula,  or  the  opening  between  the  bladder  and 
vagina  may  be  no  larger  than  a  pin's  point.  The  symptoms  arc 
leakage  of  urine*  from  the  vagina,  and,  imless  great  care  is  main- 
taincKl  by  the  patient  to  keep  dry,  excoriation,  redness,  and  sore- 
ness of  the  vulva,  perineum,  and  thighs.  The  amount  of  urine  lost 
will  depend  on  the  size  of  the  opening  and  on  the  retentive  power 


of  the  vagina.  Sometimes  urmo  is  retained  in  the  vagina  while  the 
patient  is  recumljcnt,  the  pelvic  floor  being  uninjunxl  and  the  in- 
troitu8  small.  Often  when  the  fi.siula  i^  t^inail  the  i>atit!nt  may  void 
a  portion  of  the  urine  through  the  urethra  and  the  rest  will  escape 
tlu"ough  the  vagina. 

The  diagnosis  is  maile  by  the  history  of  incontinenee  and  by  the 
physical  examination.    The  digital  touch,  if  the  fistula  Ls  large,  will 


Fio*  155. — SchiTue  uf  the  Different  iSorts  of  fictiitd  FisLoliK,  not  Including 
Fistula-in-Ano.  (Gillbm.)  1.  U  re  thro  vagina  I.  2,  Vesico- vaginal.  3,  Ilecto- 
vaginaL     4.  Vesico-ut^rine.     5.  Ur«?tero- vaginal.     6.  Entero-vaginaL 

indicate  the  size  and  situation  of  the  fistiila.  The  patient  is  plaeefl 
in  the  Sims  position  and  a  Sims  speeulum  intnidueed.  Inspection 
shows  the  size»  sha|>ej  and  situation  of  tht*  fistula.  A  sound  or  ] irol^e 
passed  through  the  urethra  may  be  made  to  appear  tlirough  the 
oix^ning  in  the  vagina.  In  larger  fistuhe  the  bladder  wall  is  apt  to 
be  mucti  ijijected  (cystitis)  and  often  incrusted  with  lime  salta. 


386  DISEASES  OF  THE  VAGINA 

These  must  be  removed  gently.  Vesico-vaginal  fistula  gives  a  fine 
opportunity  to  insjject  the  bladder  and  to  catheterize  the  ureters.  If 
the  fistula  is  very  small  and  there  is  doubt  as  to  its  situation,  the 
patient  is  placed  in  the  dorsal  position  and  the  bladder  is  filled  with 
milk  and  water.  Examination  of  the  cleansed  vagina  through  a 
duckbill  speculum  will  show  the  point  at  which  the  white  milk 
leaks  through  the  fistula. 

Uretero-vaginal  fistula  is  detected  in  the  same  manner.  The 
bladder  is  filled  with  milk  and  water  and  it  is  noted  that  clear  urine 
and  no  milk  collects  in  the  vagina;  measure  the  bladder  urine  and 
that  which  gathers  in  the  vagina,  and,  if  the  two  kidneys  arc  secret- 
ing an  equal  amount,  it  is  possible,  by  finding  that  the  two  quan- 
tities are  the  same,  to  decide  that  all  the  urine  from  one  ureter 
escapes  into  the  vagina.  The  sense  of  smell  is  a  great  help  in  de- 
tecting the  presence  of  urine,  for  in  some  instances  the  differentia- 
tion of  watery  fluid  coming  out  of  the  uterus  or  the  peritoneal  cavity 
from  urine  is  not  easy.  To  aid  in  distinguishing  urine  in  crises  of 
vaginal  fistula  it  is  sometimes  of  use  to  give  the  patient  five  drops 
of  doubly  distilled  turpentine  on  a  lump  of  sugar  three  times  a 
day.  It  imparts  the  characteristic  odor  of  violets  to  the  urine. 
Methylene  blue,  one  to  two  grains  every  four  hours  given  by  the 
mouth,  renders  the  urine  a  bluish-green  color.  The  colored  urine 
may  be  seen  to  escape  from  a  fistula. 

Urethro-vaginal  fistula  is  a  rare  variety  of  fistula  due  to  syphilitic 
or  malignant  ulceration  or  operation  on  the  urethra.  The  opening 
between  the  urethra  and  vagina  is  generally  small  and  is  situated 
in  the  upper  course  of  the  urethra.  There  is  no  incontinence  of 
urine  imless  the  fistula  involves  the  neck  of  the  bladder.  The 
diagnosis  is  made  by  passing  a  probe  into  the  urethra  and  through 
the  fistula.  For  fistulie  involving  the  bladder  and  ureters  see  also 
Chapters  XXIV  and  XXV,  pages  474  and  492. 

Recto-vaginal  fistula  results  in  the  late  stages  of  cancer  of  the 
cervix  and  also  in  the  case  of  neglected  ixjssaries  and  imperfect 
union  of  a  lacerated  perineum.  Rarely  this  fistula  results  from 
syphilitic  or  tubtTCulous  lesion  of  the  vagina.  The  opening  is 
generally  small  in  size. 

The  symptoms  are  the  escajx^  of  flatus,  and  also  more  or  less  fluid 
feces,  into  the  vagina.  Vaginitis  and  vulvitis  are  apt  to  result  from 
the  irritation  caused  by  the  fecal  matter. 


FISTULiE  OF  THE  VAGINA  387 

The  diagnosis  is  founded  on  the  history,  and  on  the  examination. 
The  patient  is  placed  in  the  dorsal  position  and  the  anterior  vaginal 
wall  raised  by  a  Sinis  speculum.  If  the  fistula  can  not  be  seen  a 
probe  is  passed  in  the  most  likely  spots  and  if  it  enters  an  opening 
which  connects  with  the  rectum  its  point  may  be  felt  by  a  finger  in 
that  organ.  Also,  one  may  inject  the  rectum  with  milk  and  water 
and  note  its  escape  into  the  vagina. 

Entero-vaginal  fistula  is  rare.  It  results  generally  from  a  surgical 
operation.  The  presence  of  feces  in  the  vagina,  the  exclusion  of  an 
opening  into  the  rectum  by  means  of  inspection  of  the  rectum 
tlirough  a  proctoscope,  the  character  of  the  fecal  matter  (chyme), 
and  finding  the  opening  of  the  fistula  in  the  upper  vagina  on  in- 
spection and  probing  with  the  patient  in  Sims  position,  will  establish 
the  diagnosis.    For  fistula-in-ano  see  Chapter  XXVI,  page  516. 


CHAPTER  XXI 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  VULVA 

Anatomy,  p.  388 :    Age  changes,  p.  391. 

Congenital  Anomalies,  p.  391:  Malformations  of  the  vulva  as  a  whole, 
p.  391.  Development  of  the  external  genital  organs,  p.  392.  Anomalies, 
p.  393.  Malformations  of  the  clitoris,  p.  393.  Malformations  of  the 
labia  majora,  p.  394.  Malformations  of  the  labia  minora,  p.  394.  Mal- 
formations of  the  hymen,  p.  396.  Imperforate  hymen,  p.  396.  Hermaph- 
roditism, p.  399. 

Injuries  of  the  vulva,  p.  400. 

Inflammation  of  the  vulva,  p.  402:  Simple  or  catarrhal  ^'ulvitis,  p.  402. 
Gonorrheal  vulvitis,  p.  402.  Diabetic  vulvitis,  p.  403.  Thrush,  p.  403. 
Elephantiasis,  p.  404.  Pruritus  vulvse,  p.  404.  Kraurosis  vulve,  p.  404. 
Edema  and  gangrene,  p.  405.     Varix,  p.  405. 

Venereal  lesions  of  the  vulva,  p.  406;  Chancroids,  p.  406.  Chancre, 
p.  406.     Mucous  patches,  p.  407.     Condylomata,  p.  407.    Gumma,  p.  408. 

Tuberculosis  of  the  vulva,  p.  408. 

Cysts  of  Bartholin's  gland,  p.  408;  Abscess  of  Bartholin's  gland,  p.  409; 
Differential  diagnosis  of  cyst  and  abscess,  p.  412. 

Labial  Hernia,  p.  412. 

Benign  tumors  of  the  vulva,  p.  413. 

Malignant  tumors  of  the  \'ulva,  p.  414:  Cancer,  p.  414;  Differential 
diagnosis  of  cancer,  p.  415.     Sarcoma,  p.  416. 


ANATOMY 

The  tiTin  vulva  is  ai)plicd  collectively  to  the  structures  often 
called  the  external  genital  organs,  and  includes:  the  mons  veneris, 
the  labia  majora  and  minora,  the  clitoris,  the  vestibule,  and  the 
hymen. 

The  Mons  Veneris. — ^The  mons  veneris  is  the  eminence  in  front  of 
the  symphysis  i)ubis.  It  is  formed  by  a  collection  of  subcutaneous 
fat  and  is  covered  with  coarse  hair,  gencTally  of  the  same  color  as 
the  hair  of  the  head.  The  upper  limit  of  the  hair  is  a  horizontal 
line,  differing  from  the  male  pubic  hair,  which  is  continued  up- 
ward along  the  linea  alba  in  a  V  shape.  Below,  the  hair  is  con- 
tinuous with  th(»  hair  on  the  outer  surfaces  of  the  labia  majora. 

The  Labia  Majora. — These  are  two  thick,  parallel  folds  of  skin 

388 


ANATOMY 


380 


extending  from  the  mons  veneris  neai'ly  to  the  anus.  They  are 
wider  above  and  grow  thinner  a,s  they  approach  the  perineum 
where  they  are  lost.  Each  fold  is  called  a  liilnum  iiiajus  and  the 
o[>ening  where  the  two  meet  in  the  midtlle  hue  i.s  caWvd  the  pu- 
drndal  slit  (rirna  piidench).  The  posterior  limit  of  the  slit  is  a 
transverse  eutantHms  fold  calleil  the  fourchette,  the  de])ression 
Ix'twetm  this  anrl  tfie  \}im'  of  the  hymen  being  the  fossa  navicularis. 


FiG>  l^^^Diagram  of  the  VuJva.     (DickinsonO 

The  labia  majora  are  pigmented  more  than  the  surrounding  skin 
and  the  outer  surfaces  contain  sebaceous  glands  and  an?  covercxl 
with  more  or  less  hair,  the  hair  becoming  scanty  and  short^  to- 
ward the  posterior  parts.  The  inner  surfaces  of  the  labia  majora 
are  smooth,  and  the  tliin  skin  covering  them  resend>les  nmcous 
mi^mbrane  in  the  \nrgin,  but  is  harder  in  the  parous  woman.  The 
outer  ends  of  the  rountl  ligaments  become  lost  in  the  upper  por- 


390  DISEASES  OF  THE  VULVA 

tions  of  the  labia  majora,  which  are  made  up  of  fat  and  connec- 
tive tissue. 

The  Labia  Minora^  or  Njrmphss. — ^These  are  two  thm,  pink,  deli- 
cate folds  of  skin  extending  from  the  frenum  of  the  clitoris  above, 
downward  to  be  lost  on  the  inner  surfaces  of  the  labia  majora  at 
about  the  level  of  the  opening  of  the  vagina.  They  are  developed 
from  the  margins  of  the  genital  cleft.  They  have  no  hairs  but 
abundant  sebaceous  glands.  Each  fold  is  a  labium  minus,  and 
the  two  labia  may  be  asymmetrical.  In  the  virgin  the  lesser  labia 
are  entirely  covered  by  the  greater  labia,  but  imder  abnormal 
conditions  the  nympha3  may  project  beyond  the  labia  majora, 
and  in  this  case  they  are  pigmented. 

The  Clitoris. — ^This  is  a  rudimentary  penis  developed  from  the 
genital  eminence,  but  it  is  without  a  urethra  traversing  it  (see  Fig. 
157).  It  is  situated  between  the  labia  majora  and  is  concealed  by 
the  upper  portions  of  these  structures,  it  is  about  an  inch  and  a 
quarter  long,  and  arises  from  the  pubic  arch  by  two  crura,  which 
unite  to  form  the  body  of  the  clitoris.  At  its  tip  is  a  glans,  which  is 
covered  partially  or  wholly  by  a  prepuce,  that,  coming  from  above 
aqd  partially  encircling  the  glans,  is  prolonged  downward  into  the 
labia  minora.  The  clitoris  is  made  up  of  erectile  tissue  and  the 
glans  is  covered  by  a  very  sensitive  epithelium.  At  the  base  of  the 
glans  are  sebaceous  glands  which  secrete  smegma. 

The  Vestibule.-^The  space  between  the  clitoris  above,  the  en- 
trance of  the  vagina  below,  and  the  nymphse  on  the  sides  is  the 
vestibule.  It  is  developed  from  the  urogenital  sinus,  is,  roughly, 
triangular  in  shape,  and  is  pierced  in  its  centre  by  the  external 
orifice  of  the  urethra,  (meatus  urinarius)  which  presents  a  longi- 
tudinal slit  closed  by  two  little  lips  (labia  urethrae)  which  form  a 
slight  elevation  above  the  surface  of  the  vestibule. 

The  Hymen. — ^This  is  a  thin,  circular,  white  or  light  pink,  per- 
forated membrane  which  separates  the  vulva  from  the  vagina. 
It  is  made  uj)  of  connective  tissue  and  elastic  fibers  and  is  covered 
on  both  sides  with  stratified  epithelium.  Its  shape,  thickness, 
and  even  its  situation  vary  in  different  cases.  The  opening  into 
the  vagina  (introitus  vaginao)  is  generally  in  the  anterior  part; 
it  may  be  ring-shaped  (annular),  admitting  the  tip  of  the  forefinger; 
this  is  the  commonest  condition,  or  it  may  be  cribriform/  fimbriate, 
horseshoe-fihaped,  septate  or  linear.    The  tissues  of  the  hymen 


C30NGENITAL  .\KOMALlES 


391 


may  bo  tough  and  resistant,  though  generally  friable  and  torn  with 
the  first  coitus  or  even  by  vaginal  examination,  always  by  parturi- 
tion. The  remaijis  of  the  torn  hymen  are  calk*<i  canineuhe  myrti- 
formes.  In  the  infant  and  embryo  the  hymen  projects  fonvard 
into  the  cleft  between  the  labia  in  the  form  of  two  apposed  longi* 
tudinal  hps,     (See  Figs.  I6,"i  to  170,) 

The  Glands  of  Bartholin. — These  glands  furnish  a  clear,  glair};*  lu- 
brieating  mucus  for  coitus  and  for  the  delivery  of  the  child  during 
lalx)r.  They  arc  two  in  number,  each  is  about  the  size  of  a  large 
pvB.  auil  is  situated  at  the  side  of  thc^  jX)sterior  part  of  the  vaginal 
canal  in  tiie  sphincter  vaginae  muscle.  The  opening  of  the  canal 
of  the  gland  is  a  minute  pin-point  hole  to  be  found  in  the  |X)sterior 
portion  of  the  inner  surface  of  the  laljium  majus.  In  wonif^n  who 
have  lx>rne  children  it  is  just  outside  the  last  and  oiipermost  car- 
unciiJa  myi-tiforinis. 

Age  Changes 

Infancy.— In  infancy  there  is  no  visible  hair  on  the  mons,  and 

the  labia  majora  are  rounded  and  firm,  the  labia  minora  projecting 
bci^ween  tlieni  as  slightly  elevated,  pink  fokis.     (See  Fig.  203,) 

Puberty. — At  puberty  hair  grows  on  the  mons  and  the  outer 
surfaces  of  the  labia  majora,  the  latter  lx*coming  pigmented  antl 
increasing  in  size  so  that  they  conceal  the  nymphie.  The  nymi>hie 
may  grow  larger  after  pol)erty»  and  if  they  do,  the  exposed  {>arts 
become  pigmented  and  of  coarser  texture.  Enlargement  of  the 
nvTiipha*  has  lx?en  ascril>ed  to  masturbation,  and  it  is  likely  that 
sucli  is  sometimes  the  case,  though  this  is  not  the  only  cause. 

Old  Age. — The  hair  on  the  mons  and  labia  majora  becomes 
gray  and  is  shetl  soon  after  the  hair  of  the  hejuL  After  the  meno- 
pause the  mons  loses  its  fat  gradually  and  the  labia  sfirink  so  that 
in  old  age  the  orifice  of  the  \ulva  ga}}es.  The  hymen  if  uidjroken 
shiinkjs,  and  the  introitus  vaglme  is  narrowed  in  any  event* 


r 


CONGENITAL  ANOMALIES 


Malforations  of  the  Vulva  as  a  Whole,— True  congenital  anom- 
alies of  the  vulvii,  such  as  complete  atresia  of  the  vulva,  arc  very 
rare  and  occur  for  the  most  part  in  nun-viable  fetuses.    There  are 


392 


DISEASES  OF  THE  VULVA 


on  record,  however,  one  ease  of  double  \Tilva  in  an  adult,  and  many 
cases  of  infantile  vulva  where  the  labia  majora  and  minora  were 
small  and  flat,  the  introitus  narrow,  and  the  mons  veneris  not 
prominent  and  poorly  providwl  with  hair.  Such  a  condition  is 
usually  associated  with  poorly  developeil  general  physic]ue.  Pro- 
eoeious  flevelopraent  of  the  \ailva  is  found  sometimes  in  conjunction 
with  precocious  menstruation  in  very  young  children.  In  these 
cases  the  breasts  also  show  alinormal  development.  In  the  chapter 
on  diseases  of  the  vagina,  page  356,  I  have  referred  to  the  not  in- 
frequent occurrence  of  a  normal  \^Iva  and  normal  body  form 


Ghm  (hlbri^i^^^ 


Gfotkd 


Otntfalfoki 


AriMS 


FiQ.  157. — ^The  External  Genital  Organs  at  the  Beginning  of  the  Third  Month 
of  Fetal  Life.     (After  Keibet) 


associated  with  a  rudimentary  uterus  ami  vagina*  An  apprecia- 
tion of  the  steps  in  the  development  of  the  several  parts  of  the 
urogenital  system  is  a  necessity  for  the  proper  understanding  of 
the  difTerent  congenit^al  malformations  of  the  external  genitals. 

Development  of  the  External  Genital  Organs. — At  the  enil  of  the 
first  month  of  intra-uterine  exif^tence  there  is  developed  in  the 
outer  siuf  ace  of  tlie  caudal  region  of  the  embryo  a  depression  in  the 
skin  (Fig.  158),  which  grows  dei*i>er  mitil  it  reaches  the  allantois 
and  rectum  to  form  the  cloaca  (Fig,  159).  Alxiut  this  time  ap- 
pmrs  the  genital  eminence  above  the  cloaca,  flanked  on  civch  side 
by  a  fold  of  skin.  The  genital  eminence  in  the  female  becomes 
later  the  clitoris^  and  the  folds  of  skin  the  labia  majora,  the  njmiphjF 
Ix^ing  developeil  on  their  itmer  siuface^.     (See  Fig,  157.)     Figure 


CONGENITAL  AXO!^ULIES  393 

160  shows  the  iliffcrLmtiation  of  the  bladder  and  reetuni  from 
tlie  allantois  and  hin<:i  gut  re.s|K»etively,  and  the  beginning  of  tht^ 
fnnnation  of  the  jxTineuni  by  the  downward  extension  of  the 
jjerineal  septum  lx*tween  the  reetutn  and  the  yrog:enital  sinus, 
whieh  has  been  formed  by  a  union  of  the  ducts  of  Midler  and  tlir 
eloaea.  The  prortodeumj  the  pot^erior  portion  of  the  invagination 
of  the  skin  that  is  to  form  the  anus,  is  now  diffejvutiated  In 
Fig.  161  the  uretlu-a  has  tx^n  formed  and  a  septum  divides  the 
urinary  from  the  genital  tract.  Figure  162  (at  about  the  end  of 
the  fourth  month)  shows  the  vagina,  although  not  yet  with  a  canal, 
ilevelopefJ  from  the  duets  of  Miiller  and  se^paratal  by  the  hjmien 
from  the  vulva.  The  perineum  lia,"*  its  mature  shape  and  the  anus 
now  opens  backwarrh  The  vestibule,  the  chtoris,  and  both  sets  of 
labia  are  already  formed,  although  they  do  not  assume  their  final 
shajx:  mitil  the  fifth  or  sixth  month.  The  externa!  genital  organs 
are  at  birth  much  more  comj>!etely  developed  than  the  internal 
organs,  whieh  remain  in  a  more  or  less  rudimentary  condition  until 
the  child  is  eight  or  ten  years  old. 

Anomalies* — Persistence  of  the  Urogenital  Sinus, — This  is  most 
often  met  with  as  an  opening  of  the  anus  into  the  vagina,  **  anus 
vaginalis '^  so  called,  in  which  there  is  incontinence  of  feces  IxM*ause 
of  the  absence  of  the  spliincter  ani  muscle.  There  is  met  with  rarely 
a  hi/pospadiaSj  or  a  connection  of  the  iwethra  with  the  vagina  high 
up,  the  vestibular  canal  lx4ng  long.  Another  form  of  hypospadias, 
also  rare,  is  the  condition  where  there  is  no  in-ethra  and  the  bladdiT 
ojxjns  directly  into  the  vestibular  canal.  In  thi»se  cases  therc^  is  of 
necessity  incontinence  of  urine  and  the  blmlder  opening  can  Ix^ 
Been  in  the  anterior  wall  of  the  vagina. 

Occasionally  a  casi>  of  persistent  cimeu  is  met  with,  the  jxTineal 
septum  and  the  sphincter  ani  not  beting  developed.  Incontinence 
of  feces  exists  in  such  cases. 

Matformadons  of  the  Clitoris* — The  clitoris  may  be  absent,  it  may 
be  small,  it  may  Ix*  hypcrtrophied,  it  may  Ix*  cleft,  as  in  episfmdm,s, 
or  the  prepuce  may  be  adherent.  Absence  o(  the  clitoris  is  an 
extremely  rare  occurrence,  and  so  is  cleavage  of  the  clitorLs,  but 
the  organ  is  found  very  small  not  infrecjuently,  and  large  cjuite  com- 
monly. Sometimes  the  clitoris  attains  the  size  of  a  small  pyerile 
jxnis.  Such  a  condition  has  no  clinical  significance  and  requires  no 
treatment  unless  it  interferes  with  coitus, — an  unusual  happening. 


394  DISEASES  OF  THE  VULVA 

An  adherent  prepuce,  on  the  other  hand,  may  be  the  source  of 
sexual  irritation  and  conduce  to  masturbation,  and  in  children 
may  be  the  cause  of  enuresis,  some  writers  even  attributing  the 
existence  of  symptoms  of  grave  derangement  of  the  general  ner- 
vous system  to  this  as  a  cause.  All  women  who  apply  for  gyncs 
cological  treatment  should  be  examined  with  reference  to  the 
adhesions  of  the  prepuce.  The  prepuce  should  be  pushed  upward 
with  two  fingers  until  the  glans  can  be  distinguished.  By  the  use 
of  gentle  pressure,  aided  if  necessary  by  the  flat  end  of  a  surgical 
probe,  the  prepuce  may  be  separated  from  the  glans.  Hard,  white 
specks  of  retained  smegma  not  larger  than  a  pin's  point  are  gen- 
erally found  under  the  adherent  prepuce.  Some  authors  maintain 
that  adhesion  is  a  condition  normal  to  the  prepuce  in  both  sexes. 
The  number  that  are  found  to  be  adherent  in  girls  and  women,  if 
every  case  coming  under  observation  is  examined  for  this  con- 
dition, has  been  surprisingly  large  in  my  experience,  and  my  own 
view  is  that  adhesion  of  the  prepuce  in  the  girl  and  woman  plays 
a  much  less  important  role  in  the  causation  of  symptoms  than  in 
the  boy  and  man. 

Malformations  of  the  Labia  Majora. — ^The  following  malformations 
have  been  described,  although  all  must  be  regarded  as  extremely 
rare.  Absence  of  the  labia,  rudimentary  labia,  multiple  labia, 
hypertrophy  of  the  labia,  and  adhesions  of  the  labia.  The  only 
ones  that  require  comment  are  multiple  and  adherent  labia.  The 
former  consists  of  longitudinal  division  of  the  labia  into  several 
folds  of  skin  instead  of  one,  and  the  latter  is  a  part  of  apparent 
vulvar  atresia.  If  the  closure  is  complete  the  child  is  non-viable. 
Generally  there  is  a  small  opening  anteriorly  through  which  mic- 
turition takes  place. 

Malformations  of  the  Labia  Minora. — ^The  same  malformations 
as  in  the  case  of  the  labia  majora  have  been  met  with.  The  two 
that  need  description  are  hypertrophy  of  the  labia  and  adherent 
labia.  Hypertrophy  of  the  nymphce  is  by  no  means  rare.  It  reaches 
a  stage  of  extreme  development  in  the  *' Hottentot  apron,"  so- 
called,  in  which  the  labia  extend  downward  some  seven  or  eight 
inches  between  the  thighs.  This  condition  is  unknown  among  the 
women  of  civilized  races.  A  moderate  degree  of  hypertrophy  is 
not  uncommon  and  is  of  no  importance  unless  it  interferes  with 
coitus.     Adherent  labia  represent  inflanmiatory  affections  during 


FiQ.  160.- The  Blaiider  Ib 
Formed,  also  the  Be^nning  of  the 
Urethra  and  the  Vagina,  Both 
Dpenin^  intrj  the  rmgenital  Sinus. 
The  Rectum  opeos  Separately 
into  the  Froctodeutn. 


Hfsn^AiSJ 


%rtn€**^ 


FfQ.  1B2. — Complete  Development.  The  Urogenital  Sinus  Has  Be- 
(Xirae  the  Vestibule.  The  Hymen  nearly  Closes  the  Opening  of  the  Viigina, 
which  Has  Become  Enlarged.  The  Kectum  is  more  Capacious  and  the 
Anus  Opens  Backward  Posterior  to  the  fully  Developed  Perineum, 


FiOB.  158- U>2.  Five  Diagrams  of  Longitudinal  Mej^ian  Sections  of 
Elf  BR  Y  OS,  Illustratinq  the  Btjlqes  of  Development  up  the  GbnitaIj 
Okoa^s.     (After  SchroederJ  395 


396  DISEASES  OF  THE  VULVA 

fetal  or  infantile  life.  The  union  is  generally  incomplete?  and 
there  is  an  opening  through  which  urine  can  escape.  Imme- 
diate division  of  the  two  labia  is  demanded  if  there  is  no  open- 
ing when  a  child  with  this  deformity  is  bom,  otherwise  it  is 
non-viable. 

Malformations  of  the  Hymen. — ^Authorities  are  divided  as  to  the 
structures  from  which  the  hymen  is  developed.  Pozzi's  view  of 
its  development  ("  Traits  de  Gynecologic/'  quat.  ddit'n,  p.  1383) 
seems  as  near  the  facts  as  any.  It  is  that  the  hymen  is  developed 
in  the  fifth  month  from  both  the  vagina  above,  after  fusion  of 
the  Miillerian  ducts,  and  from  the  vestibular  canal, — a  vestige 
of  the  urogenital  sinus, — below.  Gellhom  {Amer.  Jour.  Obstet., 
Aug.,  1904,  p.  145),  who  has  studied  this  question  most  carefully, 
thinks  that  the  indications  point  to  the  hymen  being  derived  from 
the  Miillerian  ducts  exclusively. 

The  hymen  has  never  been  found  absent  by  competent  observers. . 
As  has  been  stated  in  describing  the  anatomy,  the  form  of  the  hy- 
men varies  much  in  different  individuals,  also  its  thickness.  Of 
the  different  forms  in  which  the  hymen  is  found,  the  fimbriate  or, 
denticulate,  the  sei)tate,  the  cribriform,  the  annular,  the  linear  and 
the  crescent,  the  annular  and  crescent-shaped  hymens  are  the  most 
common.  The  hymen  may  be  so  tough  and  resistant  that  it  is  not 
ruptured  by  attempts  at  sexual  intercourse,  on  the  other  hand  it 
may  be  so  dilatable  that  it  stretches  to  accommodate  the  penis  with- 
out tearing.  The  rule  is  that  it  is  generally  torn  by  intercourse,  and 
always  by  parturition.  Cysts  and  solid  tumors  of  the  hymen  have 
been  described,  but  they  are  excessively  rare. 

Imperforate  Hymen. — ^The  opening  in  the  hymen  may  be  ex- 
tremely minute  and  yet  pregnancy  may  ensue.  A  case  has  been 
recorded  by  H.  L.  Horton  {Boston  Med,  and  Surg,  Jour.,  vol.  82, 
p.  33)  of  a  patient  who  was  in  labor  with  a  hymeneal  opening 
measuring  only  one-sixteenth  of  an  inch  in  diameter.  From  the 
most  recent  researches  the  view  has  gained  ground  that  imper- 
forate hymen  is  a  misnomer,  the  condition  being  one  really  of 
atresia  of  the  vagina,  for  in  many  of  the  cases  recorded  after  the 
liberation  of  retained  menses  a  hymen  has  been  foimd  outside  the 
obstructing  membrane.  In  other  words,  the  lower  end  of  the  va- 
gina, which  is  a  solid  structure  in  the  early  stages  of  development 
after  the  fusion  of  Miiller's  ducts  and  before  the  canal  is  formed. 


398 


DISEASES  OF  THE  VULVA 


remains  impervious  iii  the  sKlult.     Be  the  cause  what  it  may,  the 
result  is  a  damming  up  of  the  uterine  secretions  with  msuJtiag 
hematocolpot^,  hcmatometra  and  even  hematosalpinx. 
The  vulva  of  every  female  infant  should  be  inspected  by  the 
obstetrician  and  the  patency  of  the  orifice 
of  the  vagina  determined  bypassing  into 
it   a  catheter.     Most  easels  of   imi>erforate 
hymen  are  not   discovered  until  puberty, 
in  rare  instances  the  malformation  has  not 
been  suspected  untU  early  marriage.    There 
may  l>e  few  symptoms,  and  these  nothing 
more  than  a  sense  of  wxnght  and  fulhic*ss  in 
the  pelvis.    As  the  accumulated  blood  in- 
lll      creases  in  amount  the  patient  may  experi- 
ence eolicky  pains  in  the  abdomen  and  in- 
terference with  micturition  and  defeeation- 
Anienorrhea,  w^hen  the  body  shape  and  the 
psychic  changes  of  puberty  amiounee  the 
presence   of   that  state,  should   lead  to  a 
local  examination,   especially   if    there  is 
a  menstrual  moli- 


FiG*  17L— Hemato- 
colpos,  Gauseci  by  Aire- 
Bia  of  the  Vagina  or 
Imperforate  Hymen. 


men. 
[>ifignods  of  Im- 
perforate Hymm,— The  diagnosis  n^sts  on 
the  physical  examination .  Inspection 
show^s  a  bulging  in  the  region  of  the  in- 
troitus  vaginie  wliieh  is  of  a  bluish  tinge. 
The  urethral  orifice  is  dilated.  Recto- 
alxlominal  pali)ation  reveals  the  presence 
of  a  fluctuating  mass  in  the  region  of  the 
vagina;  if  the  case  is  an  eai'ly  one,  the 
vagina  alone  may  be  ililated,  if  a  later 
case  the  uterus,  or  the  uterus  and  t!ie 
tubes  are  enlargetl  (see  Figs.  171,  172  and 
173.)  The  utmost  gentleness  should  l)e 
employed  antl  it  is  wise  not  to  make  too 
exact  a  ciiagnosis  because^  of  the  danger  of 
rupturing  the  tubes,  should  they  be  distended.  A  more  precise 
finding  is  gained  after  an  anesthetic  has  been  administered,  and 


Fig  .    172.— Heiiia(uin>ljK>8 
and    Hemat4jinetra. 


CONGENITAL  ANOMALIES 


399 


this      ouli]  not  bo  given  until  the    preparations  have  been  made 
for  evacuating  the  fluid. 

Hermaphroditism. — Hermaphroditism  (Hermes  and  A|>lirodite), 
the  union  of  the  two  sexes  in  one  indivitlual,  is  a  term  generally 
used  to  de.serilx^  a  person  whojso  external  genital  orgiuis  partake  of 
the  eharacteristics  of  both  sexes.  Every  embryo  is  in  the  begin- 
ning potentially  both  male  and 
female;  some  prepomlerating  in- 
fluence ileterminhig  the  deve)o|> 
ment  of  the  Wolffian  or  the  Miil- 
lerian  duets,  so  tliat  it  is  not 
strange  that  reimiaids  of  the  un- 
ileveloped  duets  should  Ix*  fomid 
in  the  adult.  The  steps  of  the 
ilevelopment  of  tlie  sexual  organs 
are  mdieated  in  Fig,  71,  page  198 
and  in  Figs.  1;>S-162. 

True  HemmpkroditimL — A  true 
herma[>hrodite,  according  to 
Neugebauer,  is  an  individual  who 
ean  impregnate  another  and  also 
ean  be  inipregnated  it.^*If  by 
another  individual ;  not  only  that, 
it  niay  impn*gnate  itself.  Areord- 
ing  to  this  definition  true  hermaphroditism  occurs  in  the  lower 
animals,  as  in  the  eestoiKMls.  Tlie  gastrojjods,  on  the  other  hand, 
can  fructify  each  other  but  not  themselves.  True  hermaphrmlitism 
in  the  functional  sense  does  not  occiu*  in  man.  but  in  the  sense  that 
an  indi\idual  may  have  a  genital  gland  which  contains  both 
ovarian  and  toticular  tissue,  an  ovotestis,  five  undoubted!  cases 
liave  bc^sen  rej>orted,  by  V.  Sal^n,  Garr^,  Pick,  and  Schickele.  One 
of  Pick's  tw^o  cases  was  that  of  a  woman  who  had  borne  several 
chiltlren  ami  Garre's  case  was  that  of  a  male  hermaphrodite  twenty 
years  old.  Tiierefore,  true  liermaphrtxlitLsm,  defintHl  as  the  occur- 
rence of  a  combination  gland  of  both  ovary  and  testicle  in  the  vsame 
person,  does  occur.  A  iireponderating  number  of  the  n*pfjrted 
cases  are  instances  of  pseudohermaphroditisuL  Neugelriauer  in  his 
exhaustive  work  has  gathered  together  1^886  cases  of  pseudoher- 
maphroditism m  aildition  to  the  five  cases  of  true  hermaphroditism. 


Fig.  173. — Hematocolpos,  Homato- 
metra  and   llematoBalpiax. 


400  DISEASES  OF  THE  VULVA 

Pseudoherniaphrodiiisrn. — Pseudohermaphroditism  is  more  often 
of  the  male  variety. 

Male  False  Hermaphroditism. — Here  the  body  form,  statm^, 
hair,  and  breasts  are  of  the  male  type;  testicles  are  always  present, 
but  the  external  genital  organs  are  malformed.  The  penis  is  un- 
dersized and  the  glans  imperforate,  while  the  penile  urethra  is 
represented  by  a  groove  running  into  a  cul-de-sac  which  corre- 
sponds to  an  incomplete  vulva.  The  two  halves  of  the  scrotum 
have  failed  to  imite  in  the  median  line,  thus  resembling  the  labia 
majora,  and  enclose  a  rudimentary  vulvar  orifice  scarcely  admit- 
ting a  finger  tip.  One  half  of  the  scrotum  may  contain  a  testis,  and 
the  other  testicle  may  be  in  the  inguinal  canal.  It  is  a  condition  of 
hypospadias  in  the  male.  There  are  many  varieties  of  this  type. 
The  cases  are  apt  to  be  regarded  as  females  and  are  brought  up  as 
girls  imtil  after  puberty  when  they  show  sexual  inclination  toward 
females. 

Female  False  Hermaphroditism. — ^This  is  less  common  than  the 
male  kind.  The  ovaries  are  always  present,  but  may  be  in  the 
labia  majora.  The  boily  form,  stature,  and  hair  are  of  the  female 
type,  but  the  individual  may  have  a  beard  and  the  breasts  may  be 
poorly  developed.  The  clitoris  is  large,  resembling  a  penis,  the 
labia  majora  are  fused  in  the  median  line  so  that  they  are  like  a 
scrotum,  and  the  vagina  is  small. 

For  a  complete  exposition  of  this  subject,  with  descriptions  and 
illustrations  of  the  many  cases  of  hermaphroditism  that  have  been 
reported,  the  reader  is  referred  to  Neugebauer's  work  ("Her- 
maphroditismus  beim  Menschen,"  1908). 

INJURIES  OF  THE  VULVA 

Injuries  of  the  vulva  may  be  divided  into  (a)  those  due  to  child- 
bearing,  (6)  those  due  to  direct  violence,  and  (c)  those  due  to 
coitus. 

(a)  Childbearing. — ^Thc  labia  majora  are  apt  to  be  bruised  and 
lacerated,  more  often  the  former,  by  the  obstetric  forceps.  Lacera- 
tions are  generally  sup(»rficial,  l)ut  may  involve  the  vulvo- vaginal 
glands.  Hematoma  of  tJw  labium  mxijus  occurs  occasionally  follow- 
ing difficult  labor  and  may  attain  great  size.  It  is  especially  liable 
to  occur  in  patients  who  have  suffered  with  varix  of  the  vulva 


INJIUIIES  OF  THE  VULVA 


401 


during  late  pregnancy.  Hematoma  ih  diagnosofl  by  a  tense  sfweliing 
of  a  dark  eoior,  due  to  the  clotte<l  blooii  showing  through  the  skin 
of  the  labium^  and  it  is  very  sent^itivc  on  pressure,  Sueh  a  lienia- 
toma  verj^  seriou.sIy  eoniplieates  labor.  The  nynifihte  are  torn  now 
and  then,  but  nuch  woonxls  are  s^'kiom  serious.  The  veMilutleinay 
1m^  torn  near  the  clitoris  so  that  dangerous  hemorrhage  may  result, 
but  this  is  an  imusual  occuiTence.  Injuries  of  the  hymen  have 
lxH:*n  referred  to  under  the  malfomiations  of  the  hymen,  page 
396,  and  lacerations  of  the  pcTineum  arc  treated  oi  the  chapter  on 
diseases  of  the  vagina,  page  372. 

(6)  Direct  Violence. — The  \ailva,  Ix^aiisc*  of  its  situation,  Ls  pn>- 
tected  from  the  ojore  coirirrion  forms  of  injurj'.  I^ut  may  bt^  injured 
by  falls  Bestride  of  a  sharj)  object,  or  by  kicks,  or  blows.  The  close 
j>roximity  of  the  unyielding  lx)ny  arch  of  the  pulj<^s  and  the  abun- 
dant bloo<i  supply  of  the  parts  make  wouiids  in  this  region  more 
serious.  Women  have  fallen  astride  of  a  chair,  or  a  pitchfork,  or 
the  saddle  of  a  bicycle,  or  a  fence  picket,  with  resulting  wound  of 
the  vulva,  generally  attendeil  by  excessive  bleetUng.  Blows  or 
kicks  are  apt  to  take  effect  on  the  labia  majora  with  resulting 
fwmalomaj  generally  of  one  labium,  and  sometimes  of  considerable 
size.  The  hematoma  may  supinirate,  become  gangrenous,  or,  if  not 
of  a  severe  grade,  may  Ix^  absorbed.  The  dark  blotxl  generally 
shows  through  the  skin ;  the  hematoma  is  not  often  larger  than  a 
closed  fist,  and  of  course  is  very  sensitive.  Children  have  Ix^en 
injured  by  stilinters  of  wood  penetrating  the  vulva  while  sliding 
down  a  Ix>ard,  or  by  bi4ng  tlu*own  on  sharp  objects  while 
coasting. 

(c)  Coitus* — Injury  of  the  hymen  at  the  first  intercourse  often 
results  in  bleeding  which  ha^  Imm  known  to  be  alarming  in  amount 
in  very  rare  ease«;  usually  the  bleeding  is  of  no  moment.  Severe 
injury  of  the  vulva  from  rape  upon  young  girls  has  been  reported, 
the  wound  involving  the  fK^rineum,  labia,  or  even  the  rr^cto-vagmal 
septum,  there  being  cases  on  recoril  where  a  recto-vagina!  fistula 
resultexi  from  brutal  coitus.  Dispro|>ortion  in  the  size  of  the  penis 
and  the  vagina  in  the  ease  of  young  girls  and  ol*i  women  has  given 
rise  to  injmies,  wliich  niiLst  Ix;  considered  as  of  infrequent  occur- 
rence. 


402  DISEASES  OF  THE  VULVA 


INFLAMMATION  OF  THE  VULVA:  VULVITIS 

The  vulva,  being  covered  by  modified  skin  and  hair,  is  affected 
by  the  same  sort  of  skin  diseases  as  the  other  hairy  parts  of 
the  body.  The  forms  of  skin  diseases  that  most  frequently  affect 
the  vulva  are,  erythema,  eczema,  herpes,  acne,  tuberculosis,  con- 
dylomata, kraurosis,  elephantiasis,  thrush,  pediculus  pubis,  syph- 
ilis, erysipelas,  diphtheria,  and  gonorrhea.  The  last  is  the  most 
frequent  of  the  causes  of  inflammation  of  the  vulva;  other  causes 
are,  lack  of  cleanliness,  irritating  vaginal  discharges,  or  irritating 
urine,  as  in  diabetes  mellitus,  local  irritation,  as  from  scratching 
or  an  ill-fitting  napkin,  and,  finally,  any  constitutional  exhausting 
diseases  that  lessen  the  resisting  power  of  the  tissues. 

Simple  or  Catarrhal  Vulvitis. — Simple  or  catarrhal  vulvitis  is  the 
most  common  form  of  vulvitis  and  may  be  due  to  want  of  cleanliness, 
pediculi  pubis,  excessive  coitus,  abnormal  discharges  from  the  uterus, 
fecal  or  urinary  fistulse,  or  malignant  disease.  In  the  acute  form 
it  is  characterized  by  tenderness,  burning  and  throbbmg  at  the 
vulva,  smarting  on  urination,  and  profuse,  non-purulent  discharge. 
In  the  chronic  form  itching  and  burning  are  noticeable  S3rmptoms, 
also  a  discharge  that  is  thinner  and  less  in  quantity  than  in  the 
acute  stage  of  the  disease.  The  vulva  is  congested  and  more  or 
less  swollen  in  its  various  parts  and  there  may  be  excoriations  or 
even  ulcerations.  In  some  cases  the  hair  and  sweat  follicles  are 
infected  and  the  vulva  is  studded  with  papules  and  pustules.  This 
follicular  vulvitis  is  a  rare  form  of  vulvar  inflammation  seen  mostly 
in  the  clinics  of  Europe.  In  diphtheritic  vulvitis  a  characteristic 
gray  membrane,  composed  of  fibrin,  is  formed  on  the  vulva,  and  a 
similar  appearing  membrane,  but  with  little  fibrin,  also  occurs  in 
I)U(»rperal  cases  from  the  action  of  bacteria  other  than  the  Klebs- 
L()(»fHer  bacillus,  generally  the  streptococcus.  The  superficial 
inguinal  glands  take  up  infective  matter  from  the  vulva  and  even 
in  the  simple,  catarrhal  vulvitis  may  be  enlarged.  The  disease  has 
no  tendency  to  invade  thc^  vagina  or  urethra  and  microscopic  ex- 
amination shows  the  absence  of  the  gonococcus. 

Gonorrheal  Vulvitis. — In  this  variety,  by  all  odds  the  most  fre- 
quent form  of  \ailvar  inflainination,  the  disease  has  a  tendency  to 
invade  the  neighboring  organs,  and  we  have  vaginitis,  endocervi- 


mPL/VMMATION   OF  THE    VULVA 


403 


» 


citfe,  urethritis,  anil  inflammation  of  Skene's  and  Bartliolin's  glands, 
as  well  as  the  vuhitis  proper;  the  \iilviti.s,  in  fact,  being  the  least 
important  of  the  gonorrheal  prwesses.  The  discharge  is  purulent 
antl  of  a  yellow  or  greenish-yellow  color;  the  disease  alTocting  tlie 
urethra  early,  there  is  burning,  and  frequent  micturition  frorn  the 
beginning.  The  inguinal  glands  may  be  involved  and  a  **bubo'' 
is  developed  in  the  course  of  a  few  days;  also,  the  -^ndvo-vagioal 
glands  are  apt  to  be*  infected.  The  diagnosis  rest^  on  the  severity 
of  the  inflammation  following  a  suspicious  intercourse,  on  the 
[jresence  of  urinary  sj^mptoms,  on  being  able  to  expre^ss  a  drop  of 
pus  from  the  urethra  or  one  of  Bartholin's  glands,  and  on  finding 
the  gonoeoecus  in  the  cliscliarge.  Gonorrheal  \^lvitis  is  not  un- 
common among  infants  and  little  girls,  especially  in  institutions, 
and  may  lead  to  adhesions  of  the  labia  minora  or  even  the  labia 
majora.  The  entire  vulvar  cleft  may  Ix'  closed  except  a  small  open- 
mg  either  in  front  or  Ix^hind  through  which  the  lu-ine  escapes. 
Lesser  degrees  of  adhesions  are  by  no  mc^ms  rare,  and  careful  ex- 
aminations of  the  women  who  present  themselvc^s  in  the  out-patient 
clinics  will  reveal  many  causes  of  agglutination  of  portions  of  the 
nyniphff ,  or  adhesions  burying  the  glans  clitoridis. 

Diabetic  Vulvitis. — Diabetic  vulvitis  is  an  ujflammation  of  the 
^'iilva  caused  by  the  decomposition  of  the  urine  iudialx»tcs  mellitus 
by  the  saccharomyces  fungus.  Its  symi>toms  are  burning  and 
intense  itching,  and  tenderness  of  the  \Tilva.  On  uispeetion  the 
vulva  is  of  a  dull,  n^ldish  color  and  the  surfaces  of  the  labia  an* I 
vestibule  are  parchment-like,  corrugated,  and  dry.  Excoriations 
from  seratcliing  are  to  be  expecte^l,  or  even  the  presence  of  small 
lx>ils,  and  in  time  the  disease  affects  the  skin  of  the  mons  veneris 
and  the  insides  of  the  thighs  and  the  anal  region.  The*  diagnosis  is 
made  by  finding  sugar  in  the  urine  and  by  the  ap{xarance  of  the 
vulva,  which  is  most  characteristic. 

Thrush  of  the  Vulva.^ — This  rare  disease  is  caused  by  the  Saechar- 
om3'<;e.s  aibicuiks,  just  as  in  the  case  of  {mrasitic  stomatitis.  It  is 
found  most  often  in  nursing  women,  in  advanced  dial>etc*s,  tub<T- 
culasis,  cancer  and  in  women  who  are  exhauste^l  physically.  The 
parts  affeeted  are  covered  with  slightly  elevated,  snow-white  siK)ts, 
which  have  a  tendt^ncy  to  coalesce  ami  leave  shaUow  ulcers.  The 
fiaecharomyces  fungus  in  the  form  of  mycelium  and  six)res  may  be 
found  in  the  discharges  scraped  from  the  sui'face. 


404  D1SE.\SES  OF  THE  VULVA 

Elephantiasis  of  the  Vulva. — Elephantiasis  is  extremely  rare  ex- 
cept in  tropical  climates.  It  affects  mostly  the  labia  majora,  but 
may  involve  the  clitoris  or  the  nympha}.  It  occurs  between  the 
twenty-fifth  and  fiftieth  years  of  life,  and  is  characterized  by 
thickening  and  enlargement  of  the  tissues,  sometimes  forming  a 
large  tumor  that  has  fissures  and  ulcerations  on  its  surface. 

Pruritus  Vulvae. — ^This  is  a  symptom  which  may  be  due  to  a 
variety  of  causes,  and  consists  of  intense  itching  of  the  vulva.  (Sec 
also  Chapter  X.,  page  160.)  The  various  skin  diseases  such  as  eczema 
and  pediculosis  are  characterized  by  itching,  also  the  vulvitis  due 
to  diabetes,  and  the  presence  of  Ascaris  lumbricoides  and  Oxyuris 
vennicularis,  especially  in  young  subjects.  Lack  of  cleanliness 
may  cause  itching  and  so  may  irritating  discharges,  as  well  as  con- 
gestion of  the  vulva,  as  in  varicose  veins  of  the  vulva  and  in  preg- 
nancy. Aside  from  these  definite  causes  the  terminal  nerve  fila- 
ments in  the  vulva  may  be  affected  so  that  itching  results,  as  in 
the  case  of  some  old  women  and  in  certain  nervous  diseases,  and 
we  arc  ignorant  of  the  causation.  For  the  purposes  of  prognosis 
and  treatment  it  is  important  to  determine,  as  far  as  possible,  a 
definite  cause.  Great  sensitiveness  of  the  vulva  may  be  due  to  a 
neuritis  affecting  the  nerves  of  this  region,  and  the  physician  wll 
do  well  to  rule  out  this  affection  before  resorting  to  local  treat- 
ment. 

Kraurosis  Vulvae. — Kraurosis  vulva?  is  a  progressive  atrophy 
and  contraction  of  the  tissues  of  the  vulva  of  unknown  cause, 
occurring  mostly  after  the  age  of  forty.  The  disease  affects  the 
nympha^  clitoris,  and  vestibule  and  begins  as  small  brown  spot^, 
of  irregular  shape  and  slightly  depressed,  on  the  surface  of  the  labia 
minora  and  the  vestibule.  Soon  the  tissues  of  the  vulva  become 
tense,  shining,  white,  and  contracted;  the  meatus  urinarius  pnv 
sents  a  reddened  promhient  appearance,  and  along  the  caruncuhe 
myrtiformes  arc  small  patches  of  subcutaneous  hemorrhage.  The 
nymphui  atrophy.  The  orifice  of  the  vagina  becomes  contracted 
so  that  it  will  barely  admit  the  tip  of  a  finger  without  causing 
hemorrhage  or  great  pain.  The  pubic  hair  has  a  peculiar  stubbly 
appearance  and  may  be  brokc^n  or  may  come  out.  The  labia  majora 
are  not  much  affected  by  th(»  atrophic  process,  as  a  rule.  Micro- 
scopic examination  of  the  tissues  shows  small-round-celled  infil- 
tration and  great  development  of  fibrous  tissue,  with  absence  of 


INFLAMMATION   OF   THF   niLVA 


405 


hair  fullick'S  atiil  i^t'lmeeous  glamls.  1x11  to  iisvU  the  disoaso  nins 
a  i'lironic  courj^e  uf  five  or  six  years.  The  sj^mptoms  arc  great 
irritatiuri»  srnaitiiig  on  urination,  and  i)ainful  intercourse,  wliich 
may  cause  laeeratJons^  the  parts  iK^ng  very  friatjie;  the  lacerations 
Ix'ing  severe  if  pregnancy  and  klx>r  occur.  The  symptoms  may  be 
entirely  relieved  when  the  atrophic  process  has  readied  its 
ehmax.  The  chagnosis  is  established  by  the  ajjpearaiiee  of  the 
vulva. 

Edema  and  Gangrene  of  the  Vulva. — Edeina  of  tlje  vulva  may 
oct*ur  as  a  result  of  vnhitis,  Imt  is  more  commonly  tlie  result  of 
interference  with  the  jielvie  circulation  by  pressure  on  the  [x^lvic 
veins  by  tumors,  pelvic  iiiflaTrmiatory  masses,  or  the  iiregnant 
uterus,  or  it  may  form  a  part  of  a  general  anasarca.  The  nyrnphu^ 
and  the  prr^puce  of  tlie  clitoris  are  the  parts  mostly  affectnl^  l>ut  in 
extreme  cases  the  labia  majora  and  even  tlie  nions  veneris  become 
enonnously  distended.  Pitting  of  the  tissues  on  pressure  is  the 
diagnostic  sign  to  bi*  looked  ior.  Giingrene  may  follow^  excessive 
edema  or  erysi|)elas  of  the  vulva,  eras  a  complication  of  the  exan- 
themata, also  in  dirty,  undei^(*d  children,  where  it  is  analogous  to 
noma,  or  as  an  epidemic  puerperal  disease,  or  an  ^cute  inflammation 
indr'pendent  of  contagion.  The  nyni))hae  are  the  portions  of  the 
\ulva  most  affected  by  gangrc»n(\  It  In'gins  usually  as  a  livid  retl, 
indurated  swelling  of  one  laliiym,  soon  breaking  down  into  dirty 
gray  or  dull  red  ulcerations  anil  followeil  by  a  gret*nish-blaek  layer 
of  gangrene, 

Varix  or  Varicose  Veins  of  the  VuJva. — Varix  is  found  often  < luring 
the  later  months  of  prc*gnancy.  The  enlarged  veins  are  in  the 
labia  majora,  and  one  or  lx>th  sides  may  bc^  involved,  the  left 
mon*  often  than  the  right.  The  vulva  Ix-ing  well  supplied  with 
bhxxl-vessi»ls  and  also  with  erectile  tissue,  it  is  not  siu-prlsing  tliat 
obstruction  to  the  veins  should  result  in  varix.  The  dark  veins  may 
Ik*  S4*en  through  the  skin  of  the  laljiuni,  an<l  to  the  toucli  [iresent 
the  ehai^aeteristie  feeling  of  a  bag  of  worms,  as  in  the  case  of  vari- 
cocele of  the  scrotum.  Simitar  varicosities  are  to  be  found  in  the 
veins  of  the  ujiper  and  iimer  thigh  ^  and  also  in  the  vagina. 

Rupture  of  the  vtMus  of  the  vulva  during  delivery  results  in  a 
hematoma  of  the  vulva. 


406  DISEASES  OF  THE  VULVA 


VENEREAL  LESIONS  OF  THE  VULVA 

Venerear  lesions  include  chancroids,  chancre,  mucous  patches, 
and  condylomata  lata  and  acmninata. 

Chancroids  are  most  often  found  on  the  fourchette,  the  inner 
surfaces  of  the  labia  majora,  the  nymphae,  and  the  vestibule;  they 
are  multiple  as  a  rule,  and  are  more  common  among  the  uncleanly. 
Secondary  infection  is  usual  and  fresh  chancroids  keep  appearing; 
and  often  some  that  seem  to  be  healed  break  down  and  ulcerate 
anew.  The  lesion  begins  as  a  pustule  that  soon  becomes  an  ulcera- 
tion; the  ulceration  has  a  punched-out  undermined  edge,  a 
soft,  non-indurated  base,  which  has  a  granular,  uneven  surface 
covered  by  a  purulent  discharge.  This  discharge  is  auto-inoculable. 
The  sore  is  sensitive  to  touch.  The  chancroid  appears  about  forty- 
eight  hours  after  an  infecting  coitus  and  develops  rapidly.  Second- 
ary infection  of  the  lymphatic  glands  of  the  groin  (a  bubo) 
involves  commonly  only  one  gland  in  a  severe  grade  of  inflanmia- 
tion,  causing  pain,  and  often  suppuration. 

Chancre  of  the  Vulva. — ^This  is  relatively  rare,  an  extrargenital 
situation  of  the  initial  lesion  of  syphilis  being  more  frequent  in  the 
female  than  in  the  male.  Also,  because  of  the  inaccessibility  of 
the  parts  and  the  trifling  discomfort  to  which  they  conmionly 
give  rise,  chancres  of  the  vulva  often  escape  observation.  The 
initial  lesion  of  syphilis,  if  situated  on  the  vulva,  is  generally  to  be 
found  on  the  labium  majus;  the  next  most  frequent  situation.is  the 
fourchette,  then  the  nymphae,  the  clitoris,  and  the  mons  veneris  in 
order  of  frequency.  The  chancre  appears  as  a  hard,  red  lump  which 
soon  ulcerates;  the  induration  of  its  base  being  a  characteristic 
feature,  also  the  enlargement,  in  six  to  ten  days  after  its  appearance, 
of  the  individual  lymphatic  glands  in  most  intimate  connection  with 
it.  The  chancre  appears  after  an  average  period  of  twenty-six  days 
from  the  time  of  moculation,  and  is  nearly  always  single,  but  may 
be  multiple  if  several  abrasions  have  been  inoculated  at  the  same 
time.  The  ulcer  formed  by  the  chancre  has  smooth  edges,  often 
elevated  or  slopmg,  never  undermined,  and  the  base  is  of  smooth 
surface  and  mdurated,  and  the  secretion,  which  is  serous  and 
scanty,  is  not  auto-inoculable.     The  infection  of  the  lymphatic 


VEKKREAL  LE8I0NS  OF  THE  VULVA 


407 


glands  of  the  groins,  primary  atlenopathy,  affects  several  glands  in 

a  painless  eidargement. 

Diagno.vs  of  Chancre  of  ihe  Vulva. — The  diagnosis  of  chanere  is 
often  a  matter  of  extreme  (Uflieulty.  The  diseovery  of  the  Spiro- 
cha?ta  pallida  in  the  secretions  or  a  smear  from  the  chancre  makers 
the  iliagnosis  sure,  i^iit  failing  this  the  tlireo  most  important  points 
are,  the  long  {x^riod  of  incubation  of  the  cUsease^  the  induration  of 
the*  Imse  of  tite  sure,  and  the  erdargeinent  of  the  individual  lym- 
phatic glands  in  the  groin. 

A  rwent  writer  on  the  diagnostic  significance  of  the  spiroeluTta 
palhda,  R.  P.  Campbell,  Jouk  American  Medicat  Association^  Vol. 
LIV,  Mareli  19,  1910,  page  924),  speaks  as  follows  from  a  large 
clinical  expcTicnce  in  Montreal:  "It  should  be  possible  to  fuid  the 
spiroehreta  pallida  in  afjproximately  IfX)  per  cent  of  chancn^s  ex- 
cluding those  wliich  are  nearly  Jit^aied,  or  have  brn  actively  treatiMl, 
and  some  cases  of  niixinl  infection.  In  vie>w  of  this  fact,  treatment 
should  not  he  Ix'gim  Ixvfore  the  diagnosis  is  confirmed  by  finding 
the  spiroc'ha^te/* 

Differential  Diugno/ns. — Herpes  of  the  indva  is  exelmled  by  the 
ai»ix*arance  and  the  fc'<'l  of  the  lurpc^s:  a  superficial  grou|>  of 
vesicles  with  a  soft  base  disajipearing  after  a  short  tinu*.  The 
crojis  of  her|x^s  may  b<*  nmltiple,  while  chancTe  is  sin^l<\ 

Furuncidosiji  of  the  vulva  has  bt^en  mtsiakeo  for  chancre,  lli^rt^ 
the  boils  are  apt  to  Ix*  multiple  and  run  the  usual  coui-se  of  a 
furuncle.  The  chief  lesion  that  is  coiifouiided  with  chancre  is  the 
chancroid,  and  the  distinguishing  characteristics  of  the  two  lesions 
have  been  touchetl  y|)on  in  the  tw^o  preceding  pages. 

Mucous  Patches.— Mucous  [matches  in  the  \Tilva  are  a  fretjUrnt 
manifestation  of  secondary  syphilis.  They  occur  as  moist.  |)a|>ular 
syphilides  anil  erosions,  and  have  a  dist^harge  w*ith  a  foul  fnlor. 
The  Spirochtcta  pallida  is  abimtlant  in  scra|>ings  from  these  patrhr^s 
and  they  are  a  most  frequent  source  of  s}T3hilitic  contagion.  They 
are  apt  to  fx*  converted  into  camlylomata  lata  or  into  a  fusion  of 
8«?veral  papules  to  form  cvauliflower-like  growihs  on  the  genitals,  with 
fissures  and  ulciTations.  Condylomaia  acciiminata,  occiUTing  in 
casej^  of  gonorrhea  and  unclean  persons  with  irritating  vaginal 
discharge,  are  not  the  same  as  the  condylomata  lata.  The  acum- 
inate variety  are  pointetl,  more  w^art^like,  |x^limculated,  and  of  a 
branched,  tn^^like  character.    Their  color  may  Ix?  that  of  the  sur- 


408  DISEASES  OF  THE  VULVA 

rounding  skin,  or,  if  the  epithelium  has  been  removed  by  friction  or 
maceration,  they  are  of  a  deep  reil  hue.  They  have  a  foul  discharge 
and  may  affect  any  portion  of  the  \^lva  or  the  inner  surfaces  of  the 
thighs,  and  may  grow  to  the  size  of  a  fist. 

Gumma. — ^A  gumma  as  a  manifestation  of  tertiary  syphilis  may 
develop  as  a  round  tumor  in  the  labium  majus.  It  has  a  tendency 
to  break  down  by  a  sort  of  fatty  degeneration,  but  not  to  suppurate. 


TUBERCULOSIS  OF  THE  VULVA 

This  is  a  rare  affection,  there  being  on  record  only  some  fifteen  or 
twenty  cases.  The  disease  is  generally  seen  in  the  ulcerative 
stage  in  women  between  twenty  and  forty  years  of  age,  the  ulcers 
being  of  a  grayish  color,  of  varying  size,  with  irregular  edges,  ex- 
hibiting in  their  bases  tubercles  in  process  of  cheesy  degeneration, 
and  friable,  poorly  nourished  granulations.  The  ulcers  are  situ- 
ated in  the  vestibule  or  on  the  labia  or  perineum.  The  diagnosis 
is  often  difficult,  nmnerous  sections  of  the  ulcerated  tissues  being 
made  before  tubercles  and  the  tubercle  bacilli  are  found.  The 
inguinal  glands  are  not  affected  m  this  disease;  the  ulceration  pro- 
ceeds slowly,  having  a  course  of  from  eight  to  ten  years,  and  there 
is  no  marked  induration  of  the  tissues.  The  disease  has  been  called 
also  lupus  vulvae,  and  esthiomcnc  de  la  vulve. 


CYSTS  OF  BARTHOLIN'S  GLAND 

It  is  not  surprising  that  the  duct  of  the  vulvo-vaginal  gland, 
which  is  only  half  a  miUimeter  in  diameter  at  its  exit,  should  become 
occluded  as  a  result  of  infective  inflammation,  thus  damming  up 
the  secretions.  Gonorrheal  inflammation  is  supposed  to  be  a 
cause  for  the  obliteration  of  the  duct  of  the  canal  and  therefore  a 
cause  of  the  formation  of  a  cyst.  Be  that  as  it  may,  cysts  of  Bar- 
tholin's gland  are  of  sufficiently  common  occurrence.  They  are 
usually  unilateral,  vary  in  size  from  half  a  centimeter  to  four 
centimeters  in  diameter,  and  occur  during  the'  childbearing  period 
of  life.  The  smalkT  ones  may  be  due  to  the  occlusion  of  a  second- 
ary, branching  duct,  rather  than  the  main  duct. 


ABSCESS  OF  DARTHOLimS  GLAND 


409 


A  cyst  gives  little  trouble  as  a  rule,  though  the  la^ge^  ones  may 
interfere  with  coitus;  they  are  rarely  painful.  The  patient  gen- 
erally  gives  a  history  of  old  iiiHaoitriatinn  of  the  vulva.  Tlie 
diagnosis  consi^is  bi  deteeting  a  Huetiiating,  not  tender  swelUng  in 
the  situation  of  the  vulvo- vaginal  glanti  (see  figures  from  Huguier). 

Cysts  of  the  secondary  ducts  and  of  the  gland  itsc4f  ai*e  situate*  1 


Fio-  174,— €yBt  of  the  Left  Bartholin's  Gland.     (After  Huguier,) 

deeper  in  the  tissues  and  farther  from  the  introitus  vaginie  than 
cysts  of  the  main  duct,  and  such  cysts  may  be  multilocular,  wlien^ 

as  cysts  of  the  main  thiet  are  always  unilocular.  ^\Tien  laid  open 
cysts  of  Bartholin's  gland  are  fouu<l  to  Im*  filled  with  a  glairy, 
colorless,  white-of-egg  mucus,  and  to  be  lined  by  a  smooth  mem- 
brane, 

ABSCESS  OF  BARTHOLm'S  GLAKD 


Abscess  of  the  vulvo-vaginal  glands  is  very  common  and  is  due, 
Iji  a  large  proportion  of  cases,  to  gonorrhea.  One  gland  at  a  time 
is  affected,  as  a  rule,  moi-e  oft(*n  the  left,  and  the  tlisease  is  generally 


Fig,  175.— Abscess  of  the  Ducts  of  Botli  Bartholin's  Glands.     (After  Huguier,) 

later  stages  of  gonococcus  infection.  Then  there  is  a  recurrence  of 
heat  and  burning  in  the  vulva  with  sharp  pains,  slight  elevation  of 
temperature,  an<l  tenderness  of  the  tissues,  the  symptoms  lx*ing 
aggravated  by  staiKiiig,  walking,  and  sitting  even,  the  patient 
being  most  comfortable  in  the  recumbent  postiut*.  There  may  be 
retention  of  mine,  or  the  urine  simply  smarts.  Examination 
shows  swelling  and  edema  of  the  labium  and  sometimes  pus  escapes 


ABSCESS  OF  BARTHOLIN'S  GLAND 


411 


from  the  orifice  of  the  duct  on  the  inner  surface,  or  the  abcess  may 
be  evacuated  spontaneously  through  o|>enings  below  the  orifice. 
The  inguinal  IjTiiphatic  glands  are  affected  sometimes  and  a  "  buto  '* 
results.  After  the  subsidence  of  the  acutt;  inflammation  the  vulvo- 
vaginal gland  is  apt  to  renmin  iu  a  state  of  chronic  inflanunation 
and  a  drop  of  pu3,  perhaps  with  a  pjeenish  tinge,  or  a  muco-puru- 


» 


Pin.  176, — Ab«*ees8  cif  Both  Bartholin's  (jlands.  (AfkT  HuguMT/y  A  DtOp 
of  PiiH  is  shouTi  in  the  Urifice  of  Each  Duct.  Noto  Rdation  of  Urifioea  to 
Introltujs  Vagina. 

lent  discharge  issues  from  the  duct.    At  this  stage  the  orifice  is 

surroundf*d  by  a  red  areola  whif  h  resembles  a  flea  bite,  the  so-called 
nmcula  gonorrhoira  of  Sanger.  It  is  in  this  stage  that  infection  is 
apt  to  be  transmitted  to  the  male  and  light  up  in  his  urethra  an 
aeote  gonorrhea,  or  it  may  cause  puerjieral  sep^sis  or  ophthalmia 
neonatorum.     Relapse  Is  conunon  in  abscess  of  BarthoUn*s  gland 


412  DISEASES  OF  THE  VULVA 

and  the  opposite  gland  may  become  infected,  therefore  prompt 
surgical  treatment  is  indicated.  Smears  should  be  made  from  the 
discharges  and  exammed  for  the  gonococcus. 


DIFFERENTIAL  DIAGNOSIS  OF  CYSTS  AND  ABSCESS 

In  cases  of  long-standing  mflammation  the  tissues  may  be  so 
thickened  that  malignant  disease  is  simulated.  Microscopic  ex- 
amination of  tissue  excised  will  establish  the  diagnosis.  A  rectal 
fistula  discharging  through  the  labium  has  been  mistaken  for  an 
abscess  of  Bartholin's  gland.  Examination  per  rectum  in  such  a 
case  reveals  bra^^^ly  swelling,  and  the  opening  of  the  fistula  in  the 
bowel  may  be  made  out  by  means  of  the  proctoscope  and  the 
probe.  Hematoma  of  the  labium  makes  a  more  uniform  swelling 
than  a  cyst  or  abscess  and  feels  doughy,  also  the  skin  is  dark  in  the 
case  of  the  hematoma  and  there  is  a  history  of  injury  or  of  recent 
parturition.  Inguino-labial  hernia  appears  in  the  upper  part  of 
the  labium  and  tends  to  disappear  when  the  patient  lies  do\^Ti. 
There  is  an  impulse  on  coughing,  and  in  the  case  of  hydrocele  of 
the  canal  of  Nuck  the  swelling  is  also  in  the  upper  part  of  the 
labium,  but  it  is  irreducible.  Hydrocele  of  the  Canal  of  Nuck  is 
treated  in  the  chapter  on  the  diseases  of  the  uterine  ligaments. 
(See  Chapter  XU.,  page  213.) 

LABIAL  HERNIA 

An  inguinal  hernia  not  infrequently  finds  its  way  into  the  labium 
majus  and  sometimes  there  is  a  double  hernia  of  this  sort.  The 
hernia  descends  through  the  inguina  canal  and  follows  the  course 
of  the  round  ligament  into  the  labium ;  this  form  of  hernia  being 
analogous  to  sctrotal  hernia  in  the  male.  The  hernial  sac  may  con- 
tain only  OHK^ntum  or  it  may  hold  intestine,  the  uterine  tubes,  the 
ovaries,  or  even  th(^  uterus.  It  is  caused  by  the  failure  of  the.  canal 
of  Nuck  to  become  obliterated.  The  patient  complains  of  pains  in 
the  re^on  of  the  hernia,  especially  on  exertion,  and  is  apt  to  suffer 
with  dyspepsia  and  constipation.  If  the  hernia  is  reducible  the 
lump  in  the  vulva  disappears  when  the  patient  is  m  the  recumbent 
posture. 


BENIGN  TUMORS  OF  THE  VULVA 


413 


If  tiie  sac  contains  oniciitiini  the  swelling  is  irregular  in  fwl, 
provided  the  fat  over  t(i<^  tumor  i.s  not  excessive  in  amount,  thus 
obscuring  the  tactile  sen^i*.  Tht-  pereussion  note  is  flat  and  there 
is  no  gnrglmg  sound  in  it  when  reduced  and  very  little  impulse  on 
eoughhig. 

If  the  henual  sac  contains  intestine  the  swelling  is  smooth,  regu- 
lar, and  elastic.  It  is  increased  in  size  and  heenines  more  tt'iisr  on 
coughmg  or  strainhig,  and  if  rediieible  disapix'ars  or  becomes 
smaller  when  the  patient  lies  down.  As  the  hernia  goes  back  into 
the  alxloniinal  cavity  a  gurgling  soimd  is  heard.  The  tumor  of  the 
labium  is  tynipantic  to  percussion  and  an  impulse  is  transmitted 
to  it  when  the  patient  coughs. 

Shook!  an  ovary  Ix'  in  the  hernial  sac  pressure  will  cause  puin 
similar  to  tlie  pain  experienced  when  tlM^  nnrmai  ovary  is  pressed 
between  the  hngers  in  a  bimanual  examination. 

If  the  uterus  is  in  the  sac  bimanual  examination  of  the  pcJvis 
will  n^veal  tlie  al>sence  of  the  uterus  from  its  usual  situation. 

Differential  Diagnosis. — Hernia  into  the  lal>ium  must  Im*  *hffer- 
entiated  from  hydrocele  of  the  canal  of  Nuck,  from  a  tumor  of  the 
labium,  or  a  cys-t  of  Bartholin's  gland.  From  the  first  it  is  distin- 
guislied  by  the  fact  that  it  is  tympanitic,  hasan  impulse  on  coughing, 
may  have  an  irregular  contour,  is  reilueibk%  and  has  gurgling  on 
re<luction.  Hydrocele  is  irreducible,  is  of  smooth  outline^  lias  no 
impulse,  and  is  flat  to  percussion.  A  solid  tumor  of  tlie  labium  is 
generally  of  liard  consistency;  it  projects  from  the  surface,  him 
no  impulse*  on  coughing  and  no  gurgling.  A  cysi^  of  Bartholin's 
gland  is  globular,  lias  no  impulse,  Ls  flat  to  percussion,  and  is  situ- 
ateii  in  the  lower  part,  of  the  labium,  wiien>as  a  hernia  is  oval,  has 
an  impulse,  may  be  tympanitic,  and  is  in  the  upper  part  of  tlie 
labium. 

BENIGN  TUMORS  OF  THE  VULVA 


These  are  fibroma,  myoma,  myxoma,  neuroma,  angioma,  lijjonia, 
and  cysts.  They  are  rare.  Most  of  them  afl'cct  the  labia  majora. 
J.  Bondi  has  found  three  s<>rts  of  cysts  of  the  labia  minora,  of  which 
the  mucous  cysts  are  the  most  fre(|iieiit.  lie  tliitiks  tliey  re|)resc*nt 
remains  of  the  W'olffian  botlies*  They  are  situated  in  the  upper  \mn 
of  the  labium.     Lipoma  may  grow  from  the  fatty  tissue  of  the 


414  DISEASES  OF  THE  VULVA 

mons  veneris  or  the  labia  majora,  or  even  from  the  nymphae,  and 
may  attain  considerable  size.  The  diagnosis  of  benign  tmnors 
can  not  be  made  exactly,  short  of  removal  and  microscopic  ex- 
amination of  the  tissues  of  the  tumor.  Slow  growth  is  the  rule,  and 
the  only  symptoms  are  interference  with  coitus  and  the  discomfort 
attending  the  presence  of  the  growth. 


MALIGNAirr  TUMORS  OF  THE  VULVA 

These  are  cancer  and  sarcoma. 

Cancer. — Primary  cancer  of  the  vulva  is  rare.  It  is  a  disease  of 
advanced  life,  usually  occurring  between  the  ages  of  forty-five  and 
sixty.  Its  most  frequent  point  of  origin  is  the  groove  between 
the  nympha  and  the  labium  majus,  but  it  may  develop  from  the 
prepuce  of  the  clitoris  or  any  of  the  structures  of  the  vulva.  The 
cancer  appears  in  one  of  three  forms,  as  a  circumscribed  elevation, 
as  a  deep  ulceration  with  infiltrated  margins,  or  as  a  diffuse  infil- 
tration. The  circumscribed  growth  is  a  firm  tumor  rising  from 
the  surface  of  the  vulva  and  more  or  less  movable  on  the  under- 
lying, infiltrated  tissues.  If  the  cancer  has  broken  down  it  is  a 
friable  lobulated  or  warty  mass,  showing  points  of  ulceration.  The 
surface  is  granular,  furrowed,  and  bright  red  in  color,  and  the  base 
is  indurated.  The  carcinoma  may  invade  the  deeper  tissues  from 
the  beginning,  not  forming  a  circumscribed  growth  on  the  surface. 
In  this  case  the  tissues  become  of  a  brawny  hardness  and  are 
thickened  over  an  area  of  considerable  extent.  This  sort  of  growth 
may  progress  very  slowly,  and  ulceration  may  not  appear  for 
several  years.  The  tendency  of  the  disease  is  to  involve  the  struc- 
tures of  one  side  of  the  vulva  and  then  to  extend  to  the  opposite 
side,  perhaps  by  inoculation.  The  lymphatic  glands  of  the  groin 
are  involved  early,  and  the  individual  glands  are  to  be  distin- 
guished as  separate,  hard  lumps. 

Cancer  of  Bartholin's  gland  occurs  as  a  round,  indurated  tumor, 
often  as  large  as  a  hen^s  egg,  in  the  lower  portion  of  the  labium 
majus.  The  tumor  is  generally  very  vascular,  and  large  vessels 
can  be  made  out  in  the  overlying  skin. 

Cancer  of  the  vulva  is  of  the  type  of  squamous-celled  carcinoma, 
and  cancer  "pearls,"  due  to  horny  degeneration  of  the  centers  of 


MALIGNANT  TUMORS  OF  THE   VITLVA 


415 


the  epithelial  nests,  are  abundant.  Like  cancer  in  other  situations 
in  the  genital  organt^,  this  form  of  cancer  has  no  symptoms  which 
are  peeuHar  to  itt^ff*  Pain  is  a  late  symptom  after  the  disease 
has  extended  and  involved  the  larger  ner\^e  trunks.  Ulceration 
causes  local  tenderness  and  a  discharge. 

Dijfermiiial  Diagnom  of  Cancer. — In  the  early  stages  of  cancer 
the  following  disea,sps must  teexehided:  tulx^rculosis,  condylomata 
lata  and  acuminata,  chancre,  chancroids,  and  urethral  caruncle. 
Tu^MTculosis  occurs  in  younger  women,  i.e.,  between  twenty  and 
forty  years  of  age,  and  is  of  slower  gro\Yt.h;  the  nodules  are  mul- 
tiple and  soft,  the  induration  of  the  base  being  absc^nt;  tulxTcles 
may  often  lx»  seen  in  the  cheesy  degenerated  areas;  and  the  in- 
guinal glands  are  not  involved.  The  microscofx?  will  settle  a  doubt- 
ful diagnosis.  It  is  to  b^  rememl>cred  that  the  two  diseases  a